No place to get sick
Bloomberg Businessweek|January 31, 2022
In the Mississippi Delta, the stress on hospitals, doctors, and nurses— and patients—just won’t let up
By Monte Reel, Photography by Ariel Cobbert

In Greenwood, an old cotton port town in the Mississippi Delta, 10 people gathered last July around a table in the center of a gray conference room. They stood with their backs straight, heads bowed. One man bent forward and pressed his palms flat on the white tablecloth.

“We ask, Father God, that you bless the administration of this hospital— our CEO, our VP,” he said. “We ask, Father God, that you bless this board of commissioners …”

The opening prayer at this particular meeting carried a little more urgency than usual, because Greenwood Leflore Hospital faced a financial reckoning.

When the prayer was done, the chief financial officer took her seat at the head of the table and projected a PowerPoint slide on the wall. She reviewed a list of recent credits and debits: the income from Covid federal aid payments, capital expenses, debt repayments, revenue. “So,” she said, “that gives us a loss of $3.3 million for the month of June.”

No one seemed surprised. “And what did we lose last month?” someone asked.

“Let me find that …” The CFO reached for a stack of papers, but another board member had committed the figure to memory: “$2.6 million,” he said.

U.S. Highway 278 between Ruleville and Mound Bayou

The stats had been grim for years in Greenwood, and at rural hospitals all over the country. From 2010 to 2020, more than 130 of the 1,800 rural hospitals in America went out of business. At the start of 2020, almost half of the rest were at “high risk” of closure, according to the nonprofit Center for Healthcare Quality and Payment Reform. The situation grew even worse as the pandemic diminished the frequency of moneymaking elective surgeries and a growing demand for health-care workers caused hospital payrolls to soar. Many hospitals were kept open only by infusions of federal money.

When the delta variant emerged in mid-2021, it zeroed in on the poorest pockets of the rural South. By late summer, the Covid death rate in Mississippi was higher than anywhere else. Cash reserves at the most vulnerable hospitals were bleeding out, and the delta variant felt like a shark going in for the kill. Nurses and doctors, and state health officials, urged patients to get vaccinations, but the issue had become as politically charged as anywhere in the country. In the middle of the delta variant surge, the state’s governor, Tate Reeves, warned that vaccine mandates amounted to “tyranny,” calling vaccination requirements for workers “an attack by the president on hardworking Americans and hardworking Mississippians who he wants to choose between getting a jab in their arm and their ability to feed their families.” Mississippi had one of the nation’s lowest vaccination rates, and it remains in the bottom four of all states.

In the Mississippi Delta—the poorest region in the poorest state—the doctors, nurses, and administrators have sacrificed and improvised, month after month, exhausting themselves to keep their hospitals afloat. Many are filled with a profound sense of duty. But they’ve come to accept the unease that comes when an institution’s survival feels arbitrary—when all the planning, thrift, and professional savvy in the world feels less important than chance. They fear the worst, do their best, and pray for miracles.

Two at-risk rural hospitals in Mississippi, including one that had declared bankruptcy months before the emergence of Covid-19, kept providing services during the pandemic by forging staff-sharing agreements with another hospital to reduce overhead costs. For others, emergency aid —like the $7.5 billion earmarked for rural providers in the American Rescue Plan last November— helped them forestall closure, but it didn’t lift them out of crisis mode.

At the Greenwood Leflore board meeting, the CFO said the hospital was given about $11 million in Covid relief funds in fiscal year 2021. But during that same period, she said, even with the help, the hospital was about $10 million in the red.

The members approved a motion to go into a closed executive session. For the next 86 minutes, they reviewed and debated a recommendation from the administrators to plug one small hole where the hospital was leaking money. Greenwood Leflore boasted the only neurosurgery unit in the Delta. The unit had a full slate of surgeries scheduled, yet it was losing money. The administration suggested the surgeon’s contract be allowed to expire. That wouldn’t stop the hospital’s financial slide, but it might slow the pace of the fall.

The board called a vote, and the ayes had it: The Mississippi Delta would go without neurosurgery as of Sept. 17, 2021.

The Delta’s last practicing neurosurgeon still had two days left on his contract when he took a lunch break at Veronica’s, a bakery tucked into a Greenwood strip mall. In the six weeks since Dr. Craig Clark learned his career in the Delta would soon be over, a turn of events he hadn’t seen coming, the rhythm of his days had changed. “Before, with general surgery, it was probably 80% spine, 20% cranial, and a majority of the cranial stuff would come through the ER—you know, subdural hemorrhages, epidural hemorrhages, that sort of thing,” he said. His patients came from all over the Delta—Greenville, Clarksdale, Rosedale, Ruleville. He even drew some military veterans from Jackson, the capital, where the VA hospital was temporarily without a neurosurgeon.

He was spending much of his time working the phones. In late July he canceled the 20 surgeries he had on the books, knowing he couldn’t provide the necessary follow-up care. “I set about trying to find these people somewhere to go, and I was completely unsuccessful,” he said, leaning in over his sandwich. “I called up people I knew in Jackson, and they said, ‘Nah, man, I’m covered up—I don’t need any more patients.’ For most of the people, I ended up telling them, ‘You’ll have to go back to your primary-care doctor and have them try to find you a spot.’ So now the primary-care doctor will do what I just did—and may or may not be more successful.”

Clark tried to envision what would happen to patients who’d need emergency neurological care in the coming months. Most would have to travel an hour or two longer for treatment than they had before. That extra distance, he believed, might be the difference between a full recovery and a permanent disability, or worse.

A series of studies analyzed by the Centre for Economic Policy Research last year found that when a rural hospital closes, the median distance for residents to access basic health services jumps by about 20 miles, and ambulance travel times increase an average of 76%. The death rate for time-sensitive conditions increases by 8.7%. The mortality increase is even higher for rural racial minorities and the rural poor—11.3% and 12.6%, respectively. The Mississippi Delta’s population is majority Black, and there’s no poorer place in America.

Clark, who’s 72, plans to seek another job elsewhere, likely outside the Delta. He grew up in Macon, Ga., where as a preteen he played bass guitar in a church band whose drummer was Otis Redding. Until his late 20s, when he turned to medicine, he’d been a session bassist at studios throughout the South—Muscle Shoals in Alabama, MasterSound in Atlanta, a few others in Nashville. These days, he connects to music in his workshop, where he crafts replicas of Gibson electric guitars.

Clark, the Delta's last neurosurgeon

“It’s something to do,” he said. “A hobby.”

He rose from the table after finishing lunch, but he didn’t plan to go back to work, even though the need for his services hadn’t changed. In the waning days of his contract, his afternoons were mostly idle.

Before stepping into his car, Clark looked across the strip mall parking lot toward a JCPenney. A yellow banner drooped across its façade: Going Out of Business. You can’t talk about the crisis in rural hospitals, he said, without talking about that banner. Clark recited a list of area stores and factories that had closed over the past 20 years. Nothing was replacing them, he said, except dollar stores.

Mississippi ranks dead last in doctors per capita, but it has more Dollar Trees, Dollar Generals, and Family Dollars per person than any other state in the union. They’re the most conspicuous of the region’s economic indicators, flashing by along with the other roadside snapshots: brick houses with sagging roofs and boarded-up windows; a Ford Taurus on a weedy lawn, no wheels, cables spilling out of the hood like a gutted fish; a couple walking on the shoulder of the highway between a cash advance store and a LoanMax.

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