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Coronavirus Is Spreading Through Rural South’s High-Risk Population – Reopening Economies Will Make It Worse

Health + Wellness
A man sits outside Chris' Barber Shop as he waits his turn for a haircut in Lilburn, Georgia on April 24, 2020. Tami Chappell / AFP / Getty Images

By Anne Cafer and Meagen Rosenthal

In the rural South, the COVID-19 pandemic is becoming a silent disaster.

As rural residents commute to jobs in cities and transportation hubs, they're being exposed to the virus and bringing it home to a population already at risk.


Chronic diseases that can lead to more severe COVID-19 symptoms are common across the rural South. The population is older and poorer than much of the country, and the health care system has been deteriorating for years as hospitals lose staff and close.

Despite the population's vulnerability, Southern states have been a stronghold of resistance to federal and international recommendations around COVID-19 protective measures. Most of the states' delays and refusals to enact "shelter-at-home" policies were tied to economic arguments.

Now, governors are using the same economic reasons for loosening those restrictions. Georgia Gov. Brian Kemp called for reopening several types of businesses, including hair salons, starting Friday and restaurants and even theaters starting Monday, despite concerns from public health officials. Mississippi is also considering lifting its shelter-at-home orders for economic reasons. When that happens, service workers, once partially protected from exposure, will find themselves at greater risk.

As University of Mississippi sociologists who work with rural communities on a range of resilience issues, especially health, we are concerned about the economic and health consequences of returning to business before the region is prepared to protect its residents.

Rural Commuters on the Urban Front Lines

Rural areas may seem isolated from the coronavirus threat, but in the South, one in 12 rural residents commutes to an urban hub for work. Many of those jobs are on the front lines of health care and service industries, where exposure to other people is hard to avoid.

In much of the South, "shelter-at-home" orders have had loose interpretations of "essential personnel" who are exempted from the order. They include employees in high-exposure jobs – cashiers, fast food workers and registered nurses, all among the largest employment areas for Southern states. Many of these workers are less likely to have sick leave or be able to work from home. And they are paid lower wages, so many still go to work even when they're sick.

These workers have been saved some exposure while restaurants shifted to drive-through operations and social distancing was encouraged. However, if other Southern states follow Georgia's lead and begin lifting their current protections, workers' chances of being exposed to someone infectious with the coronavirus rise.

Mississippi's rural infection numbers stand out in particular: 62% of the state's coronavirus cases as of mid-April were in rural counties, and the state had counted more than 200 deaths. Rural infection rates were higher than in urban areas: 181 cases per 100,000 people compared to 128 in urban counties. The South as a whole had more urban cases, but still a high rural infection rate.

The South Isn’t Prepared for a COVID-19 Surge

Southern states are already scrambling to manage both detection of coronavirus cases and treatment of the disease. Their testing capacity, essential to controlling the pandemic, has been increasing but remains sporadic and well below the national average. Access to care is increasingly difficult.

Mississippi has just over 400 ICU beds in its largest hospital service area, Jackson. Currently, 100 of those are occupied. Conservative estimates predict that needs for rural ICU beds will double to more than 800 in the next six months under moderate coronavirus infection projections.

Ventilators are an even bigger concern. University of Mississippi Medical Center has only about 125 to 150 ventilators in its facilities, and officials estimate 40% to half are in use on any given day.

The rural South's health profile adds to the risk. The region has higher rates of chronic medical conditions that have been found to significantly increase the likelihood that a person infected with the coronavirus will develop severe COVID-19. Among the first 159 people to die from COVID-19 in Mississippi, over half had cardiovascular disease, over 40% had diabetes or high blood pressure, and one-third were obese.

Much of the care for these patients is being delivered through a shrinking rural health care system. Of the 128 rural hospital closures across the country in the last 10 years, over half were in the South. The pandemic has created more financial troubles for rural hospitals as nonessential procedures have been postponed. Every county in Mississippi is considered underserved, meaning residents don't have enough doctors, even if they have access to a health care facility.

Testing and Investing in Health Care Long-Term

In the short term, Southern states need to increase their testing for coronavirus cases. Per capita, the South administered about 20% fewer tests. Many southern states currently rely on pop-up testing at sites temporarily opened in locations where other facilities are not available. Permanent, well-stocked testing centers would help residents know where to go.

In the long-term, these states need to invest in their rural health infrastructure.

Rural hospitals and pharmacies are essential to reducing long-term risk among rural Southerners, particularly those with chronic health conditions. They are also important "economic anchors" for their communities. According to the American Hospital Association statistics, every dollar spent by a hospital supports US$2.30 of additional business activity within the community and hospitals are a top source of private sector jobs.

Anne Cafer is an Assistant Professor of Sociology at University of Mississippi.

Meagen Rosenthal is an Assistant Professor of Pharmacy Administration at University of Mississippi.

Disclosure statement: Anne Cafer receives funding from Carnegie Foundation, Walmart Giving Foundation. Meagen Rosenthal receives funding from Walmart Giving Foundation, Eshleman Institute for Innovation: Discovery Grants Program, Mississippi Department of Health, UNC TraCS Institute (pilot grant).

Reposted with permission from The Conversation.

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Guillain-Barre syndrome occurs when the body's own immune system attacks and injures the nerves outside of the spinal cord or brain – the peripheral nervous system. Niq Steele / Getty Images

By Sherry H-Y. Chou, Aarti Sarwal and Neha S. Dangayach

The patient in the case report (let's call him Tom) was 54 and in good health. For two days in May, he felt unwell and was too weak to get out of bed. When his family finally brought him to the hospital, doctors found that he had a fever and signs of a severe infection, or sepsis. He tested positive for SARS-CoV-2, the virus that causes COVID-19 infection. In addition to symptoms of COVID-19, he was also too weak to move his legs.

When a neurologist examined him, Tom was diagnosed with Guillain-Barre Syndrome, an autoimmune disease that causes abnormal sensation and weakness due to delays in sending signals through the nerves. Usually reversible, in severe cases it can cause prolonged paralysis involving breathing muscles, require ventilator support and sometimes leave permanent neurological deficits. Early recognition by expert neurologists is key to proper treatment.

We are neurologists specializing in intensive care and leading studies related to neurological complications from COVID-19. Given the occurrence of Guillain-Barre Syndrome in prior pandemics with other corona viruses like SARS and MERS, we are investigating a possible link between Guillain-Barre Syndrome and COVID-19 and tracking published reports to see if there is any link between Guillain-Barre Syndrome and COVID-19.

Some patients may not seek timely medical care for neurological symptoms like prolonged headache, vision loss and new muscle weakness due to fear of getting exposed to virus in the emergency setting. People need to know that medical facilities have taken full precautions to protect patients. Seeking timely medical evaluation for neurological symptoms can help treat many of these diseases.

What Is Guillain-Barre Syndrome?

Guillain-Barre syndrome occurs when the body's own immune system attacks and injures the nerves outside of the spinal cord or brain – the peripheral nervous system. Most commonly, the injury involves the protective sheath, or myelin, that wraps nerves and is essential to nerve function.

Without the myelin sheath, signals that go through a nerve are slowed or lost, which causes the nerve to malfunction.

To diagnose Guillain-Barre Syndrome, neurologists perform a detailed neurological exam. Due to the nerve injury, patients often may have loss of reflexes on examination. Doctors often need to perform a lumbar puncture, otherwise known as spinal tap, to sample spinal fluid and look for signs of inflammation and abnormal antibodies.

Studies have shown that giving patients an infusion of antibodies derived from donated blood or plasma exchange – a process that cleans patients' blood of harmful antibodies - can speed up recovery. A very small subset of patients may need these therapies long-term.

The majority of Guillain-Barre Syndrome patients improve within a few weeks and eventually can make a full recovery. However, some patients with Guillain-Barre Syndrome have lingering symptoms including weakness and abnormal sensations in arms and/or legs; rarely patients may be bedridden or disabled long-term.

Guillain-Barre Syndrome and Pandemics

As the COVID-19 pandemic sweeps across the globe, many neurologic specialists have been on the lookout for potentially serious nervous system complications such as Guillain-Barre Syndrome.

Though Guillain-Barre Syndrome is rare, it is well known to emerge following bacterial infections, such as Campylobacter jejuni, a common cause of food poisoning, and a multitude of viral infections including the flu virus, Zika virus and other coronaviruses.

Studies showed an increase in Guillain-Barre Syndrome cases following the 2009 H1N1 flu pandemic, suggesting a possible connection. The presumed cause for this link is that the body's own immune response to fight the infection turns on itself and attacks the peripheral nerves. This is called an "autoimmune" condition. When a pandemic affects as many people as our current COVID-19 crisis, even a rare complication can become a significant public health problem. That is especially true for one that causes neurological dysfunction where the recovery takes a long time and may be incomplete.

The first reports of Guillain-Barre Syndrome in COVID-19 pandemic originated from Italy, Spain and China, where the pandemic surged before the U.S. crisis.

Though there is clear clinical suspicion that COVID-19 can lead to Guillain-Barre Syndrome, many important questions remain. What are the chances that someone gets Guillain-Barre Syndrome during or following a COVID-19 infection? Does Guillain-Barre Syndrome happen more often in those who have been infected with COVID-19 compared to other types of infections, such as the flu?

The only way to get answers is through a prospective study where doctors perform systematic surveillance and collect data on a large group of patients. There are ongoing large research consortia hard at work to figure out answers to these questions.

Understanding the Association Between COVID-19 and Guillain-Barre Syndrome

While large research studies are underway, overall it appears that Guillain-Barre Syndrome is a rare but serious phenomenon possibly linked to COVID-19. Given that more than 10.7 million cases have been reported for COVID-19, there have been 10 reported cases of COVID-19 patients with Guillain-Barre Syndrome so far – only two reported cases in the U.S., five in Italy, two cases in Iran and one from Wuhan, China.

It is certainly possible that there are other cases that have not been reported. The Global Consortium Study of Neurological Dysfunctions in COVID-19 is actively underway to find out how often neurological problems like Guillain-Barre Syndrome is seen in hospitalized COVID-19 patients. Also, just because Guillain-Barre Syndrome occurs in a patient diagnosed with COVID-19, that does not imply that it was caused by the virus; this still may be a coincident occurrence. More research is needed to understand how the two events are related.

Due to the pandemic and infection-containment considerations, diagnostic tests, such as a nerve conduction study that used to be routine for patients with suspected Guillain-Barre Syndrome, are more difficult to do. In both U.S. cases, the initial diagnosis and treatment were all based on clinical examination by a neurological experts rather than any tests. Both patients survived but with significant residual weakness at the time these case reports came out, but that is not uncommon for Guillain-Barre Syndrome patients. The road to recovery may sometimes be long, but many patients can make a full recovery with time.

Though the reported cases of Guillain-Barre Syndrome so far all have severe symptoms, this is not uncommon in a pandemic situation where the less sick patients may stay home and not present for medical care for fear of being exposed to the virus. This, plus the limited COVID-19 testing capability across the U.S., may skew our current detection of Guillain-Barre Syndrome cases toward the sicker patients who have to go to a hospital. In general, the majority of Guillain-Barre Syndrome patients do recover, given enough time. We do not yet know whether this is true for COVID-19-related cases at this stage of the pandemic. We and colleagues around the world are working around the clock to find answers to these critical questions.

Sherry H-Y. Chou is an Associate Professor of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh.

Aarti Sarwal is an Associate Professor, Neurology, Wake Forest University.

Neha S. Dangayach is an Assistant Professor of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai.

Disclosure statement: Sherry H-Y. Chou receives funding from The University of Pittsburgh Clinical Translational Science Institute (CTSI), the National Institute of Health, and the University of Pittsburgh School of Medicine Dean's Faculty Advancement Award. Sherry H-Y. Chou is a member of Board of Directors for the Neurocritical Care Society. Neha S. Dangayach receives funding from the Bee Foundation, the Friedman Brain Institute, the Neurocritical Care Society, InCHIP-UConn Center for mHealth and Social Media Seed Grant. She is faculty for emcrit.org and for AiSinai. Aarti Sarwal does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Reposted with permission from The Conversation.


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By Jake Johnson

Unity Task Forces formed by presumptive Democratic presidential nominee Joe Biden and Sen. Bernie Sanders unveiled sweeping party platform recommendations Wednesday that—while falling short of progressive ambitions in a number of areas, from climate to healthcare—were applauded as important steps toward a bold and just policy agenda that matches the severity of the moment.

"We've moved the needle a lot, especially on environmental justice and upping Biden's ambition," said Sunrise Movement co-founder and executive director Varshini Prakash, a member of the Biden-Sanders Climate Task Force. "But there's still more work to do to push Democrats to act at the scale of the climate crisis."

The climate panel—co-chaired by Rep. Alexandria Ocasio-Cortez (D-N.Y.) and former Secretary of State John Kerry—recommended that the Democratic Party commit to "eliminating carbon pollution from power plants by 2035," massively expanding investments in clean energy sources, and "achieving net-zero greenhouse gas emissions for all new buildings by 2030."

In a series of tweets Wednesday night, Ocasio-Cortez—the lead sponsor of the House Green New Deal resolution—noted that the Climate Task Force "shaved 15 years off Biden's previous target for 100% clean energy."

"Of course, like in any collaborative effort, there are areas of negotiation and compromise," said the New York Democrat. "But I do believe that the Climate Task Force effort meaningfully and substantively improved Biden's positions."

 

The 110 pages of policy recommendations from the six eight-person Unity Task Forces on education, the economy, criminal justice, immigration, climate change, and healthcare are aimed at shaping negotiations over the 2020 Democratic platform at the party's convention next month.

Sanders said that while the "end result isn't what I or my supporters would've written alone, the task forces have created a good policy blueprint that will move this country in a much-needed progressive direction and substantially improve the lives of working families throughout our country."

"I look forward to working with Vice President Biden to help him win this campaign," the Vermont senator added, "and to move this country forward toward economic, racial, social, and environmental justice."

Biden, for his part, applauded the task forces "for helping build a bold, transformative platform for our party and for our country."

"I am deeply grateful to Bernie Sanders for working with us to unite our party and deliver real, lasting change for generations to come," said the former vice president.

On the life-or-death matter of reforming America's dysfunctional private health insurance system—a subject on which Sanders and Biden clashed repeatedly throughout the Democratic primary process—the Unity Task Force affirmed healthcare as "a right" but did not embrace Medicare for All, the signature policy plank of the Vermont senator's presidential bid.

Instead, the panel recommended building on the Affordable Care Act by establishing a public option, investing in community health centers, and lowering prescription drug costs by allowing the federal government to negotiate prices. The task force also endorsed making all Covid-19 testing, treatments, and potential vaccines free and expanding Medicaid for the duration of the pandemic.

"It has always been a crisis that tens of millions of Americans have no or inadequate health insurance—but in a pandemic, it's potentially catastrophic for public health," the task force wrote.

Dr. Abdul El-Sayed, a former Michigan gubernatorial candidate and Sanders-appointed member of the Healthcare Task Force, said that despite major disagreements, the panel "came to recommendations that will yield one of the most progressive Democratic campaign platforms in history—though we have further yet to go."

 

Observers and advocacy groups also applauded the Unity Task Forces for recommending the creation of a postal banking system, endorsing a ban on for-profit charter schools, ending the use of private prisons, and imposing a 100-day moratorium on deportations "while conducting a full-scale study on current practices to develop recommendations for transforming enforcement policies and practices at ICE and CBP."

Marisa Franco, director of immigrant rights group Mijente, said in a statement that "going into these task force negotiations, we knew we were going to have to push Biden past his comfort zone, both to reconcile with past offenses and to carve a new path forward."

"That is exactly what we did, unapologetically," said Franco, a member of the Immigration Task Force. "For years, Mijente, along with the broader immigrant rights movement, has fought to reshape the narrative around immigration towards racial justice and to focus these very demands. We expect Biden and the Democratic Party to implement them in their entirety."

"There is no going back," Franco added. "Not an inch, not a step. We must only move forward from here."

Reposted with permission from Common Dreams.