Dr. Beth Oller and nurse Heather Mackey put on protective gear to make a May 21 house call in Stockton, Kansas, a town of 1,300 in rural Rooks County. Lack of access to healthcare is one reason Richard Besser is concerned about the impact of Covid-19 in rural areas. (AP Photo/Charlie Riedel)

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As businesses in communities across Appalachia – and across the country – begin to reopen, Richard Besser, M.D., has been vocal about the measures he feels should be met to counter the spread of Covid-19, most particularly, the disproportionate effect reopening too soon will have on underserved and marginalized communities.

Besser served as acting director of the Centers for Disease Control and Prevention under President Barack Obama and is now president and CEO of the Robert Wood Johnson Foundation. RWJF is the largest private institution in the country devoted solely to improving the nation’s health.

Besser is concerned about the challenges rural communities faced before and that are now more critical in the midst of the pandemic. He also worries that the pandemic is being “hyper-politicized.”

“We can’t see science, and public-health science, as the enemy of economic recovery,” Besser said. “We can’t see the interests of rural states and the interests of more urban states as being in opposition. We need to see the solutions to this as fundamental societal issues that we all have to tackle and find a way to come together around these issues.”

What’s given him cause for hope, Besser said, is that “there’s been a lot of legislation that’s been passed in Washington with near unanimous support. And that’s a good thing. I hope we can get back towards that.”

He spoke with 100 Days in Appalachia’s Taylor Sisk about his concerns for rural communities.

This interview has been edited for length and clarity.

Taylor Sisk: We’ve been reading for a while about the potential risk of Covid-19 to rural communities. I’d like to talk about how that’s now manifesting. Do you anticipate the rural infection rate rising to the level of urban areas? And what are you now seeing that alarms you or that maybe gives you reason for hope?

Dr. Richard Besser: What we’re seeing now across the nation, as there’s more and more data available and as the virus spreads, is that rural communities are seeing some of the biggest growth in cases. There’s data showing that in rural middle-American states, the rate of increase is about twice that of the national average. That is concerning. It’s concerning because I worry that the call to reopen the economy, people’s fatigue with staying home and people’s need to earn an income is potentially out of sync with the risk that is still there in so many places.

TS: Statistically speaking, rural communities are older. They have lower incomes. They have poor access to health care. In the context of Covid-19, demographically, what concerns you the most about the health of rural communities?

Richard E. Besser, M.D., president and CEO of the Robert Wood Johnson Foundation (Photo submitted)

RB: All of those factors put people in Appalachia at an increased risk.

The good news about Covid is that the vast majority of people who get this infection will do well. But older people or people with underlying medical conditions are at increased risk of dying from this. In communities where the population is older, that’s a problem. In communities that, economically, are on the edge, It’s a problem.

People are being forced to make really hard decisions about going to work and having money to put food on the table and pay rent, or staying home and away from others so they can help protect themselves and their families and communities. And if it’s a community where incomes are lower, and there’s less savings, there’s not much of a choice there. People are going to be out and about more, and that increases their risk.

In so many parts of rural America, we’re seeing hospitals and other health-care facilities close. And that’s a challenge, because what you want is that if someone is developing symptoms they have the opportunity to be tested, to know if they have Covid, that they’re provided with support so that they can isolate away from family members and others. And we know that in rural America very many people live in households with multi-generations. So while someone who is sick may not be in a high-risk group, there could be several people at home who are and there may not be the space to be able to isolate away from other people.

These things all put people at increased risk of not just having Covid infection but of having more severe infection and spreading it to others.

TS: Even in communities with low infection, there’s a lot of stress over the threat of catching a virus, over finances, over the unknown. Can you talk about the repercussions of that stress on both behavioral and physical health?

RB: We know that in the short term we deal with stress well, physically. The feeling of stress gets us to change our behavior; that fight-or-flight feeling of stress helps you run from danger.

But when that stress occurs over time, day in, day out, over extended periods, it’s not good for our bodies; those stress hormones become very dangerous. And for people who are exposed to chronic stress, it sets them up for other health issues, inflammatory issues, whether it’s heart disease or lung disease or increases in the risk of infectious diseases.

So chronic stress is not a good thing  the stress of worrying about where finances are coming from, from losing jobs, of all of a sudden having your kids at home and not only having to be a mom and a breadwinner but also a teacher and a principal. There’s a lot of stress on everybody. Thinking about how to use public-health science to get people back to work in as safe a way as possible is critically important.

TS: In an op-ed piece for USA Today, you wrote, “Those who have been historically marginalized in our country must not be marginalized again in a rush to reopen.” 

A large percentage of rural residents are blue collar workers. A large percentage work in the service industry. As we reopen our communities, these people are being told to go back to work, and I’ve heard some among those workers say that while they’re being referred to as essential, they feel that they’re being considered expendable. What are your thoughts on how much risk is acceptable as we reopen?

RB: The second part of that is: Who has to accept that risk? That idea of who’s essential and who’s expendable is so important to talk about. We know that people of color and lower-income people have been more likely to be in the category of essential worker, have been more likely to get Covid, have been more likely to be hospitalized and more likely to die.

As the economy opens up and people are being told to go back to work, we can’t continue down this path of saying that lower-income workers, essential workers, are also expendable workers. We need to make sure that everyone who’s going back to work is doing so based on the best principles: So, cases have to be going down. There has to be room in hospitals and health-care facilities not just for people with Covid but for people to be seen for all of their medical issues. We need to make sure that for every industry that’s coming back online, there are agreed-upon standards for how to protect workers and that they’re enforceable.

There’s such a power differential when someone in the service economy is told to come back to work. They get there and they’re told, “Well, it doesn’t look good for you to wear a mask.” What can they do? The option is not go to work and not get paid or not wear a mask and increase your risk. So we want to make sure that workers are protected as they’re coming back online, and that they’re not coming back to jobs until the conditions in their particular communities are such that it’s safe to do so.

TS: I know you said that as we reopen, we must “embrace the fight.” And I think that’s what you’re describing there. What all does embracing that fight entail?

RB: Well, from a public-health standpoint, it means demanding that there’s data so that you can see problems as they arise, making sure that you’re able to see who’s getting infected and who’s getting hospitalized, who’s dying based on race and ethnicity, geography and income level, so you can see if particular communities are getting hit hard and look to address that.

You want to make sure that testing is available widely, and that you’re looking at the testing rates broken down in the same way so that you can identify particular areas where there isn’t enough testing or where the testing is showing that there’s ongoing transmission.

And I think one of the hardest things, and most important things, is that when someone is infected, or they’ve been exposed, you need to work with people in communities to identify safe places for them to spend that 14-day period when they could be spreading this to somebody else or they could be brewing infection. If you’re not doing that  if you’re just telling someone you’re infected and go home and isolate  you’re not recognizing that for so many people across this country that’s not possible to do without exposing other people. You’re just identifying where those little clusters and outbreaks are going to be happening; you’re not really preventing them. These are some of the short-term things.

Long term, there’s a lot we have to do to change the safety net in America. We’re the wealthiest nation in the world and we don’t guarantee paid sick leave and family leave for everybody. Less than half of the lowest-wage earners have sick leave or family leave. We don’t ensure that everyone has unemployment insurance. We have more than 28 million people who don’t have health insurance  and now so many people are losing their jobs, that number is gonna be skyrocketing. There’s so much that we need to do as a nation to show that we value each and every person and that we truly believe that, in America, everyone should have a fair and just opportunity for health.

TS: Should there be one standardized set of metrics that every community adheres to as it reopens? Or should those metrics be flexible based on demographic factors?

RB: I think that there should be a core set that everyone is using, and then areas can do more. What are the metrics that should be collected? Clearly breaking down data by location  not just state and county, but down to the zip code. Breaking down data by income, by race, by gender. If you’re doing that, you’re going to be able to see things that you otherwise wouldn’t. And right now those data aren’t available to even be able to say specifically how different communities are doing.

TS: You appeared last week on CNN Covid-19 Townhall and the hosts played a clip of President Trump in which he said of health-care workers: “They’re running into death, just like soldiers run into bullets. I see that with the doctors and the nurses and so many of the people that go into these hospitals. It’s incredible to see. It’s a beautiful thing to see.” What’s your reaction to that analogy? 

RB: When I heard that, it didn’t strike me as a beautiful thing. What would be a beautiful thing would be to ensure that every worker in America has what they need to be protected  whether you’re a health-care worker or someone providing the care that’s so needed in health-care facilities, or you’re a poultry worker or meat processor or someone putting food on shelves so that people can go to the store, or you’re driving a bus  whatever it is you’re doing. It would be a beautiful thing if every single person had the protective gear that they needed so that their risk wasn’t any higher than it had to be. And what I said was, what those workers are doing is heroic. They are heroes, just as all the other essential workers are heroes. But it’s not beautiful that in America we’re letting people put themselves in a risky situation where they shouldn’t have to have the level of risk that they currently do.

TS: I’d like to pull another quote from your op-ed. This is something that really stuck with me: 

“Whether because of lack of access to health care, low household income, immigration status, racial discrimination, disability, lack of safe or affordable housing or myriad other factors, millions of people are going to pay for our nation’s interest in equities that have existed for generations. They’ve become even more apparent and appalling, during this pandemic.” 

What do we need to do as a nation to bridge these disparities in vulnerability that are based on where you live, how much money you make, the color of your skin?

RB: These are profound societal questions. As we look across rural America, and we look at areas where there’s been major disinvestment, what can we do to spur investment in communities so that we’re supporting people in rural America, hard-working people, people who want a good-paying job that will allow them to take care of their family and save some money for the future? How do we spur that investment? There’s a lot of money that’s going to be coming forward to try and spur our economy during recovery. We need to apply that kind of equity lens and ensure that those dollars are going to some of the hardest-hit communities, communities that were in danger before this pandemic. You have communities that are truly at risk of going away because of this pandemic.

TS: Is it a different set of issues if we’re talking about bridging disparities in health care between rural and urban communities, as opposed to bridging those disparities among races and ethnicities? Or are these fundamentally the same issues?

RB: There are different drivers for different issues. Rural America is extremely diverse. There’s a ton of data that shows that when you add issues of racial disparity, income disparity, geographic disparities together, it’s more than additive. So if you’re looking at the prospects for Black Americans, Latino Americans, indigenous people, they’re worse at every income level. There are, fundamentally, things that have to be addressed from the perspective of structural racism that’s entrenched in our society, in our history. Beyond that, though, there are issues that are affecting people of every race in every community in rural America and the needs of rural America are critically important, regardless of race.

This article is republished with permission from 100 Days in Appalachia.