COVID-19 is increasingly spreading in rural North Carolina communities, adding a strain to areas already lacking health care specialists.
"I'm quite worried actually," said Dr. Erin Fraher, the deputy Director of Policy at UNC's Sheps Center for Health Services Research. "Initially when we started to see the impact it tended to be in urban areas. It's really gone to hotspots in rural communities which tend to have fewer health care providers."
Inequalities in health care access are not new but like so many other industries, the pandemic has highlighted just how deep these gaps are.
The Sheps Center for Health Services Research has analyzed the distribution of critical care personnel and respiratory therapists across North Carolina since the start of the pandemic. The Center's analysis found the state's emergency care workforce is densely clustered in counties with academic health centers.
Counties like Orange and Durham have more than 20 critical care nurses for every 10,000 residents whereas many counties report less than five nurses for every 10,000 people.
"Sometimes the data does tell a story I do think people need to hear and particularly around this idea of nurses and the real big short fold of nurses we have around the state," Fraher said.
Similar gaps are seen in the distribution of critical care physicians. Counties in the western and southern region of North Carolina have 1 or fewer critical care physicians for every 100,000 people, based on the Sheps Center analysis. These are the same regions that are experiencing some of the largest upticks in COVID-19 hospitalizations.
"These are the communities where we may not have the workers so we can't surge, the whole focus was, 'Let's surge our workforce' but we don't even have a workforce to surge," Fraher said.
A shortage of workers could mean patients in rural communities would have to travel farther to receive the care they need.
Maggie Sauer, the Director of the Office of Rural Health , said adding another barrier like transportation would make a big impact on people who work hourly jobs and have children.
"I think we're at a point right now where we're able to handle some of this but it's a tipping point and it's a real tipping point in rural because like I said many of the folks in rural don't have health insurance, they may have more additional conditions that could contribute to their contraction of COVID-19 and they may be older," Sauer said.
Another critical worker in treating COVID-19 patients is respiratory therapists, but 10 North Carolina counties don't have one and another 34 are underserved according to Bill Croft, the executive of the North Carolina Respiratory Care Board. Some of this gap is due to the counties also not having a hospital.
Croft said hundreds of respiratory therapists were needed before the pandemic so the board took steps to mitigate the need. The board relaxed some licensing requirements and started sending a list of unemployed respiratory therapists out to hospitals. Croft said those efforts have led to more than 363 new respiratory therapists to start working since March.
Despite adding staff, Croft said the state still needs an upwards of 500 more respiratory care practitioners.
Croft said the shortages of staffing is leading to increasing concern over what happens if staff get infected with COVID-19.
"If you talk about a gap, the biggest gap is the unknown and that unknown is if they come down with COVID," he said.
All healthcare workers are at risk of catching COVID-19, but if the virus spreads among workers in a county already lacking key staff, the impact could be devastating.
The NC Respiratory Care Board surveyed its members this fall and found staffing was a top concern followed by health and wellness of staff.
Across the United States, an average of 20% of hospitals that responded to a recent U.S. Department of Health and Human Services survey indicated a critical staffing shortage.
Of the hospitals that responded in North Dakota and Wisconsin, more than 40% indicated a critical staffing shortage. Only 6% of North Carolina facilities that participate indicated a shortage.
Even more, about a quarter, of the hospitals surveyed anticipated a shortage within a week. Around 9% of North Carolina hospitals that participated share that concern.
In North Carolina, Fraher said she's very concerned about burnout of employees working in the ICU every day.
"I really worry about the sustainability of that workforce. I worry about burnout, I worry about emotional distress. These are healthcare workers who have to be the only person at patients' bedside," she said.
Stephanie Reid is one of those ICU workers at Cape Fear Valley Medical Center in Fayetteville.
"It hits all of us extremely hard sometimes, we become their families. We become the hands when the family members can't be there to hold their hands," said Reid who is resource nurse in the ICU.
She particularly remembered holding an iPad up to a patient so he could speak to his family. A little while later she prayed with him as he died and cried with the family.
"Two months later did the same thing with his wife and so it takes an emotional toil because we become the families and sometimes it's not easy to turn it off so when you get home you ask for that extra hug from your loved ones because it is hard," Reid said.
Reid said her hospital is handling staffing well and hasn't had issues yet but she fears the virus won't go away.
It's the simple fact that the virus is not going away and is getting worse that has many worried about when North Carolina will hit a tipping point.
"I think people are afraid, you know? They are afraid that the numbers will increase to the point that they can't really take care of patients," Sauer said.
Sauer said addressing the gaps in health care across North Carolina isn't as simple as adding more staff to rural hospitals.
"As a state we've really been trying to look at not just healthcare but how do you make sure that people have a job, have access to food, transportation, housing," Sauer said. A large part of the solution Sauer said is expanding broadband to help expand rural communities' options for health care and work.