On Three Different Continents, Rural Health Strains under the Weight of the Coronavirus – Scientific American

Throughout the pandemic, the SARS-CoV-2 virus has laid bare weak points in the worlds health care systems. This has been true in arguably every country and every community, but the fractures have been especially apparent in rural areas, where poor access to health care long predated the pandemic.

In this three-part story, Undark explores the gaps in rural health care systems around the world, following the daily work of a village health worker in a small township in central Zimbabwe; a newly graduated rural doctor on a required year-long stint at a remote clinic in northern Ecuador; and a family doctor at a private practice in upstate New York.

Rural life in each of these countries is vastly different, and the challenges that the health care workers face, in some cases, also vary. In Hoja Blanca, Ecuador, for instance, its a three-day round trip just to send a Covid-19 test for analysis, requiring travel by motorcycle, bus, and ferry, and in Makusha Township, Zimbabwe, the health care worker gets around on a bike. Meanwhile, doctors in New York State have access to couriers and can hop in a car for house calls. There are also inequalities when it comes to vaccine availability, funding, and even access to basic medicines like ibuprofen.

But Covid-19 has also revealed common problems. There are far fewer doctors and nurses in these remote areas compared to their urban counterparts. Each rural community feels the pinch of badly broken health care systems on the national level. Covid misinformation and disinformation, as well as pandemic fatigue, reaches even the most remote areas. And as the pandemic lingers, all of the health care workers, no matter their country of origin, continue to toil to keep their villages safe.

This reporting project was created in partnership with Undark and produced with the support of the International Center for Journalists and the Hearst Foundations as part of the ICFJ-Hearst Foundations Global Health Crisis Reporting Grant.

On a recent Sunday, Lucia Chinenyanga, 42, navigates her bicycle through the bumpy terrain of Makusha Township in Shurugwi District in rural Zimbabwe, 200 miles outside the countrys capital city of Harare.

Chinenyanga, a village health worker, is headed to a nearby home to educate a family on vaccines and other Covid-19 protection measures. On her way, she meets Robert Nyoka, a local. As they talk, he expresses concern about his pregnant wife receiving her second dose of the Covid-19 vaccination.

Chinenyanga assures him its safe. Your wife can receive her second jab, she says. But should she feel any slightest side effect afterwards, she must report to the nurses to check her.

As a village health worker, Chinenyanga oversees and responds to the health needs of people in Makusha Townships Ward 9. She works at the local clinic. Her tasks include education around tuberculosis, home-based care for the elderly, monitoring pregnant women, and health awareness programsespecially on Covid-19 vaccines. The position required three weeks of training conducted by the Ministry of Health and Child Care, which coordinates health workers. She has worked in the village since 2019, the year before the pandemic hit Zimbabwe.

While nearly two-thirds of Zimbabwes 15.3million people lived in rural areas like Makusha Township as of 2020, rural health facilities in the country are often under-resourced, with fewer nurses and doctors compared to urban hospitals. Village health workers such as Chinenyanga fill the gap. And although the village health workers play an essential role in the primary health care system, providing care for the marginalized or remote communities in rural areas, they receive little paythe equivalent of $42 every month from nongovernmental organizations that work with the government.

The health sector in Zimbabwe is a mix of public and private facilities; the latter are costly, charging more and offering better services compared to government-run institutions. In Shurugwi, there are three private facilities, but most local residents cannot afford those services due to poverty and opt for the public clinics. Others rely entirely on the services of health workers who do community rounds. Shurugwi consists of 13 wards, with a population of 23,350 according to a 2014 census.

The pandemic has stretched the system even more. Over the past months, Covid-19 has increasingly become a dominant problem, killing high numbers of community members, Chinenyanga says in January following a spike in Covid-19 cases in the country. The deaths came with shortages of pretty much every necessity: quarantine facilities, personal protective equipment, medicines, and doctors. Like many places around the world, the country has also struggled with people sharing fake news about the dangers of vaccination.

Enforcing Covid-19 protocols can be draining for Chinenyanga. Every day she has to convince the rural villagers, mostly small-scale gold miners in the area, many of whom are skeptical of vaccines, to mask up, practice physical distancing, sanitize, and avoid gatherings at places like pubs, where people tend to forgo prevention measures.

Despite some pockets of vaccine hesitancy, as ofJune 7,2022, a total of4.3million Zimbabweans have been fully vaccinated for Covid-19, amounting to about28percent of the population.More than a millionhave received a booster shot.

In Shurugwi, people grew scared when family members started dying of Covid-19, Chinenyanga says. One family would lose both the wife and the husband at the same time. This is when locals started understanding that Covid-19 wasnt just a flu, but a deadly disease which had come to our community.

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When Zimbabwe gained independence from the United Kingdom in 1980, the new countrys health sector adopted a strong focused health care system, moving from only providing more advanced health care services for the urban population to involving more vulnerable sections of the society in rural areas. Health workers like Chinenyanga now play a pivotal role in the countrys health systems, says Samukele Hadebe, a senior researcher at the Chris Hani Institute, a South African think tank.

In rural areas, the health workers must be empowered with both finances and resources to do their job effectively, he adds, as a majority of people rely on them.

If you come from a health background you will realize those who have succeeded in building universal health care or a viable health care system, it is not the specialist doctors, he says. Wherever there is a successful health care system, it is actually the basic community health care, the one that in some countries where they dont even earn salaries. Those are the people fighting to just get recognized. Those are the people who manage the fundamental work.

But over the years, Hadebe says, Zimbabwes government neglected the rural health sector by not taking care of its health care professionals and paying them inadequate salaries, which pushed many qualified workers to leave the country for better opportunities overseas. In Zimbabwe, the infrastructure is gone, he adds, and health workers from the basic to the specialist are leaving the country. Why? Not just because of the salaries, but because someone will leave the country because they are worried about social security.

Zimbabwes 2010 Health System Assessment from USAID, a U.S. federal agency focused on foreign development, shows that there was a dramatic deterioration in Zimbabwes key health indicators beginning in the early 1990s. The current life expectancy for Zimbabwe in 2022 is just under 62 years, a 0.43 percent increase from 2021, according to projections from the United Nations.

With little hospital funding from the government, village health workers have to do their work with limited resources. Clinics likeChinenyangasin Makusha are poorly resourced and cannot accommodate patients with severe Covid-19 or other critical ailments, as there are no relevant medicines or oxygen tanks.

Even larger hospitals in Zimbabwe dont always provide oxygen to every patient, especially if the patient cant pay. You must have money upfront, Hadebe says. And how many people can access that? So, its a dire situation.

Itai Rusike, who heads the Community Working Group on Health in Zimbabwe, agrees that most rural health care facilities in the country were not equipped to deal with severe cases of Covid-19. In addition to the lack of oxygen tanks, he says, we also do not have intensive care units in our rural health facilities. Most of the rural facilities have no doctors, he adds, and the nurses who do work in rural areas may also not be well-equipped and skilled enough to deal with severe cases of Covid-19.

In November 2021, the Minister of Finance and Economic Development, Mthuli Ncube, announced that the country had acquired 20 million doses of vaccines. China reportedly committed in mid-January to donating 10 million doses over the course of 2022, which can be used for both initial and booster shots.

Rusike says that to ramp up the vaccination drive program, community outreach is needed, especially in rural areas. We need to take vaccination to the people, he says, rather than just wait for the people to come to the health facility and get vaccinated.

I think it is important, especially in remote locations, we come up with innovative strategies to take vaccination to the people, he adds. We know there are certain hard-to-reach areas where we can even use motorbikes to make sure that people can be vaccinated where they are, in their communities.

***

In addition to resource shortages, Chinenyanga has experienced another serious challenge most days in her work: vaccine misinformation and disinformation.

The problem is common across rural Zimbabwe, according to Rutendo Kambarami, a communication officer at UNICEF, who says that the most common reason communities are not taking the vaccine is fear.

Even though much of Zimbabwes population lives in rural areas, they still are connected on social media through mobile devicesand the mobile devices and social media platforms allow for plenty of access to inaccurate information and outright conspiracies about vaccines. So we realized that we needed to give more information in order to dispel misinformation, she said at a December workshop on Covid and mental health for journalists in Zimbabwe.

Village health workers, as front line workers, and even the teachers were saying: We needed to do more interpersonal communication within those areas. So, front line workers play an incredibly huge role in terms of even misinformation and disinformation.

As Chinenyanga wraps up her day, after visiting several homes, she agrees that social media has contributed to misinformation. The people she serves in the Makusha community often share with her unproven remedies to treat Covid-19. She lists some of the misinformation that shes seen so far. People believe in steaming, that it helps. They also believe that eating Zumbani, a woody shrub that grows in the country, also prevents Covid-19, she says.

Still, she manages to smile as she leans against her bicycle. She says she loves her job and its usefulness to the community. As village health workers, our role is to share information we are taught by the Ministry of Health, she says. We prioritize prevention as the most effective tool against Covid-19.

Karen Topa Pilalooks around the windowless reception area in the small health care station of Hoja Blanca, Ecuador, its pale yellow walls stained with patches of mold. When did the electricity go out last night? Topa Pila, a doctor in this remote corner of the country, asks. Her co-workers shrug, throwing worried glances at a small container filled with ice packs. Its only 8:30 a.m. one morning in December 2021, but outside its already over 70 degrees.

Topa Pila closes a cooler containing 52 Covid-19 nasal swabs. Those tests need to be refrigerated and we only have one fridge, which is exclusively for vaccines, she says. Her team has nowhere to store the tests, she adds, and so to avoid getting them spoiled in the jungle heat, the clinic wants to use up all of them on the same day. The very next morning, a health care worker is going to take them to the laboratory in the district hospital.

Topa Pila, 25, and her team arrived in Hoja Blanca, a village of 600 located in the heart of Ecuadors Esmeraldas province, in September 2021. As freshly graduated health care professionals, they all are required to serve an ao rural, working one year in a rural community in order to get their professional license or advance into postgraduate courses in medicine. (The Ministry of Public Health implemented the ao rural in 1970, and the practice is also common across Latin America.) Topa Pilas team is the third deployed in Hoja Blanca since the start of the pandemic. The Hoja Blanca station is also responsible for six other communities, made up of mestizos, Indigenous Chachis, and Afro-Ecuadoriansabout 3,000 people in total. Some of the communities are so remote that to reach them, the health care workers traverse thick rainforest and then travel by canoe for a whole day.

Ecuador has suffered big losses from the pandemic. In the early months,corpseslittered the streets of the countrys biggest city, Guayaquil. By June 2020, the mortality rate from the virus reached8.5 percent, one of the highest in the world at the time. As of June 5, 2022, the countryrecorded35,649 official Covid deaths, although the real count is likely far higher.

Many public health experts agree that Covid-19 has also surfaced deep-rooted systemic problems in Ecuadors rural health care system. In 2022, Ecuador, the smallest of the Andean nations, reached more than 18 million inhabitants; an estimated 36 percent live in rural communities. As with private health care providers, the countrys public health care system is fragmented, divided among various social security programs and the Ministry of Public Health. There are about 23 physicians and 15 nurses per 10,000 people on average. But only a small portion of the countrys health care professionalsroughly 9,800, by the estimate of Dr. John Farfn of the National Association of Rural Doctors serve the more than 6.3 million rural Ecuadorians.

Although Ecuador is relatively financially stable, many Ecuadorians lack access to adequate medical care and the country has some of the highest out-of-pocket health spending in South America. In rural areas, access to hospitalas well as clinics like Hoja Blancasis hampered by bad infrastructure and long distances to facilities. Before the pandemic, Ecuador was undergoing budget cuts to counter an economic crisis; public investment in health care fell from $306 million in 2017 to $110 million in 2019. As a result, in 2019, around 3,680 workers from the Ministry of Public Health were laid off. Ecuador has also experienced long-standing inconsistencies in health leadership. Over the last 43 years, the country has had 37 health ministersincluding six since the start of the pandemic.

Before the Ministry of Public Healths selection system placed Topa Pila for her service, she had never been to Hoja Blanca, and it took her more than eight hours to get there. She says that when she first arrived at the modest health care station, she thought, This is going to collapse.

Early in the pandemic, Ecuador weathered shortages in everything: face masks, personal protective equipment, medications, and even health care workers. By April 2020, the government had relocated dozens of doctors and nurses from rural areas to urban hospitals and health centers, leaving many communities without medical attention.

At one point, says Gabriela Johanna Garca Chasipanta, a doctor who spent her ao rural in Hoja Blanca between August 2020 and August 2021, her team didnt even have basic painkillers like acetaminophen or ibuprofen. It was an infuriating experience, she says. I even had to buy medication out of my own pocket to give to some patients, the ones who really needed it and didnt have the economic means to get it. Some rural outposts had to resort to desperate DIY solutions during the worst months of the pandemic, says Esteban Ortiz-Prado, a global health expert at the University of Las Americas in Ecuadorjury-rigging an oxygen tank to split it between four patients, for instance, and using plastic sheets to create isolation tents in a one-room health center.

The pandemic has strained rural doctors in other ways, too. In 2020 and 2021, Ecuadors National Association of Rural Doctors received many complaints of delayed salaries, some more than three months late. There were rural health care workers who were even threatened by their landlords that they were going to be evicted, saysFarfn, a doctor and former association president.

Even under better conditions, remote health care outposts are only equipped to provide primary care. Anything more serious requires referral to the district hospital, which in Hoja Blancas case means a 300-mile round trip to the parish of Borbn.

The health administration used to take into account Ecuadors geographical and cultural diversity and the poor infrastructure in rural areas. But in 2012, the government restructured the system into nine coordination zones that public health experts say no longer follow a geographical logic. You cannot make heads or tails of it, saysFernando Sacoto, president of the Ecuadorian Society of Public Health. This is not just a question of bureaucracy, but also something that has surely impacted many peoples health.

Although there have also been significant developments in the health care sector in the past 15 yearsincluding universal health coverage and a $16 billion investment in public health from 2007 to 2016it mostly focused on the construction of hospitals, says Ortiz-Prado. But the countrys leadership didn't pay too much attention to prevention and primary health care, he adds. The system was not built to prevent diseases, but was built to treat patients.

In 2012, the government also dismantled Ecuadors Dr. Leopoldo Izquieta Prez National Institute of Hygiene and Tropical Medicinewhich was responsible for emerging diseases research, epidemiological surveillance, and vaccine production, among other things. (It was replaced by several smaller regulatory bodies, one of which failed completely, according to Sacoto.) The majority of a nationwide network of laboratories shut down as well. Sacoto and other experts believe that if the government had continued investing in the Institute rather than dismantling it, it would have lessened the severity of the pandemics impacts in Ecuador.

Initial plans to track and trace Covid-19 cases faltered; the country had barely any machines to process PCR tests, the gold-standard Covid-19 tests. During the first days of the pandemic, samples collected in Guayaquil were taken to Quito by taxi, Sacoto says, because that was the only place PCR tests were being analyzed. But public transportation to rural communities is limited, so even the few rural residents who had access to tests sometimes waited two weeks for test results.

***

Topa Pilas team tries to convince everyone they cross paths withthe butchers wife, people waiting for the bus, men at the cockfighting arenato take a Covid-19 test. While the PCR results are faster than they used to be, they still take a week, as one of the health care workers has to personally shuttle the samples to Borbna 3-day roundtrip that involves a motorcycle, two different buses, and crossing a river with a shabby ferry. Up until yesterday, we had Covid-19 rapid tests. Today, the [district] leader took all the tests we had, says Topa Pila. The district hospital had requested the rapid tests, she adds, because theyve run out of tests and they need them.

Since Hoja Blanca is fairly isolated, the community has had very few Covid-19 cases, and all were mild. Topa Pila fears having any patients in a critical condition, Covid-19 or otherwise, because all she can do is ask the villagers and ferry operator for help with transport. There are no ambulances. We dont have oxygen because the tank we have over there is expired and you cant use it anymore, she says. Weve asked for replacement but nothing has happened.

The way Topa Pila sees it, its a lot to ask of the inexperienced health care workers on their ao rural. We start from zero without knowing anything every year, she says, recalling that the previous team had already left by the time she arrived in Hoja Blanca. And all of those patients whose treatments have been supervised by a doctor for a year lose their treatments, because they knew the doctor would come to their house, she says. We arrive and dont know where they live, since as you can see there are no addresses here. The Covid-19 pandemic has further distanced the rural doctors from their patients, she adds. Between the lockdowns and the coronavirus, other health matters like childhood vaccinations have been put off.

As in other parts of Latin America, the Covid-19 crisis in Ecuador also allowed corruption to fester. Sacoto says he believes the health care sector has become a bargaining chip among politicians. There really are mafias embedded in, for example, public procurement, he says, because the public procurement system is so convoluted that only the person who knows how the fine print works benefits. Between March and November 2020, the countrys Attorney Generals office reported196corruption cases related to the Covid-19 pandemic, including allegations of embezzlement and inflated pricing of medical supplies.

Lately, there have been signs of improvement. After taking office in May 2021, the government of Guillermo Lasso has accelerated vaccination efforts against Covid-19, approved a new program to tackle childrens malnutrition, and announced a Ten-Year Health Plan to improve health equity.

Sacoto says he remains skeptical whether these plans will translate to concrete and lasting actions. A good start would be decentralizing the health care system by building more rural clinics, he says, which could build up a network for preventative care for everything from childhood malnutrition to future pandemics. Ortiz-Prado says the country should better integrate its fragmented health care systems to make it easier for patientsand their recordsto move between them when needed. And it needs to improve the working conditions and salaries of rural health care workers to make the work more appealing, Farfn says, while also creating more permanent positions focused on rural communities. There is a lack of concern, lack of budget, he says, adding, Its a vicious circle, and sadly, governments are trying to apply Band-Aid solutions for the health issues here.

But all of that is in the future. Now, back at the Hoja Blanca health care station, the lights flicker back on in less than a day. The vaccines in the fridge are safe. But the 52 Covid-19 tests are still at risk: A health care worker must take the cooler to the lab in Borbn. There were heavy rains the night before, though, and water levels havent dropped enough for the river ferry to restart operations. Its just the first leg of what will ultimately be a 13-hour journey, and the icepacks are quickly melting amid the balmy equatorial heat.

Before Covid-19, there were no doctors in the village of Otego in central New York. Now there is one. During the pandemic, Mark Barreto quit his job at the Veterans Affairs hospital 89 miles away in Albany and opened a family medicine practice in his basement.

Just 910 people live in Otego, which sits along the Susquehanna River in Otsego County, a pastoral landscape of rolling hills and narrow creek valleys. Barreto lives on a dead-end road, a single street with pastureland on both sides. The downstairs waiting room looks like it could be anywhere in rural Americaa row of identical burgundy chairs against a pale beige wall, kids art hanging above.

In early December 2021, two of Barretos neighbors make an appointment. April Gates and her spouse Judy Tator are both in their 70s. They live around the corner. A friend joined them for Thanksgiving dinner and subsequently came down with Covid. Two weeks later, neither woman has symptoms and both got negative results with at-home tests. But theyre worried. Theyve come to take PCR tests, plus get a blood pressure check for Tator.

You dont have to be symptomatic. Its never bad to get tested if youve had a positive exposure, says Barreto. Are we being overly precautious? Maybe. But particularly with your cardiac history, youre at higher risk.

I worry most about giving it to someone else, Gates says. Thats the biggest thing.

New York State has an estimated 20.2 million residents. Two years into the pandemic, over one quarter of the population has had Covidmore than 5 million cases and more than 71,000 deaths, according to the state department of health. In the first six months of the pandemic, New York hospitals were overwhelmed with more Covid patients than beds. While they've continued to be overstretched, thelimiting factoris staffing. A similar situation has played out across the country: Medical personnel have quit in record numbers, according to the U.S. Bureau of Labor Statistics. Turnover rates were four times higher for lower-paid health aides and nursing assistants than physicians, peaking in late 2020, JAMA reported in April.

The problems are most acute in rural areas that were already chronically understaffed. We have a health care shortage in the county, in the region, says Amanda Walsh, director of public health for Delaware County, just across the river from Otego. Walsh and her nursing staff averaged 12 hour days, seven days a week, for all of 2020. It was an insane amount of time, she says. The hours only eased after the state established phone banks with remote contract tracers, and Walsh started sending her team home by six, even though the work wasnt done.

In Barretos office, after 40 minutes chatting with Gates and Tator about their health concerns, Barreto swabs both patients, walks them out, and then calls a courier to pick up the tests. While he waits, he pulls up the Otsego County webpage. The Covid dashboard shows 7,235 total cases, and the county recently broke its record for most active cases, at 386. Before December, that number had never climbed above 300.

Barreto swivels away from his desk. In the first months of Covid, he says, medical systems that were already dysfunctional simply fell apart. Commuting to Albany on empty highways, hed pass a digital DOT sign reprogrammed to read: Stay home, save lives. He took the message to heart, wondering, he recalls: What is my role as a health care provider? Because we're expected to put ourselves in harm's way to help people. The problem is we didn't know what to do to help them.

For 15 years working in hospitals, Barreto had been dissatisfied with how he saw patients treated. He notes two problems. One is getting access in a reasonable amount of time. And two is continuity of care, he says. The ongoing relationship is key, someone who knows your full story, he says, because thats what your medical history is, its a story.

When Covid hit, he adds, things only got worse.

***

With each successive wave of Covid, the disease spikes in cities and then rolls out to rural areas. Towards the second half of 2020, both case rates and mortality rates were highest in rural counties, according to USDA researchespecially those only with communities of 2,500 people and under. The study pinpointed four contributing factors: older populations, more underlying health conditions, less health insurance, and long distances from the nearest ICU.

In December, omicron followed the same pattern, peaking in New York City two weeks before it really hit Otsego County, says Heidi Bond, who directs the countys department of public health. By early January, active cases in Otsego County shot up to 1,120 before the county abruptly stopped reporting the data. The health department was swamped, Bond says, and it was not possible to get an accurate number with the limited contact tracing and case investigation that is being done.

Sparsely populated regions like central New York, which have smaller health departments and hospitals, are easily overwhelmed during surges, says Alex Thomas, a sociologist at SUNY Oneonta who studies rural health care. Otsego County has fewer than 10 public health staff working on Covid, and 14 ICU hospital beds. Neighboring Delaware County has no ICUs.

In a 2021 study of New York public health staff, Thomas and his team found that 90 percent felt overwhelmed by work, and nearly half considered quitting their jobs. A survey from the Centers for Disease Control and Prevention of about 26,200 public health employees found similar results, with anxiety, depression, PTSD, and suicidal ideation among the fallouts. Thomas predicts dire consequences: We have a serious public health emergency, and there's nobody to take care of it.

Covid revealed long-term flaws in the system, and Barreto predicts the U.S. health care system will eventually collapse on itself. Bond has a more positive perspective: Health care is stronger now after the trial by fire, largely because we know a tremendous amount more than we did two years agoabout Covid, but also about how to help institutions adapt to evolving medical needs.

Before Covid, Bond adds, public health was certainly not a priority at the state or local level. Few elected officials wanted to invest enough or plan for providing robust care for a future crisis. Establishing better partnerships with community organizations let her team overcome these funding deficiencies. Having those in place moving forward, you know, things will happen much more quickly, she says, because we know who to reach out to, to just lend us a hand.

In Otsego County, dealing with the fallout of Covid became a community effort. Volunteers sent up a local Facebook group to share information and services; it quickly had more than 1,000 members. The local hospital organized an ad hoc County Health and Wellness Committee that met biweekly on Zoom. And between 50 and 100 locals representing medicine, public health, and social service agencies, non-profits, and churches exchanged information and ideas and then stepped up to help, says Cynthia Walton-Leavitt, a pastor at a church in Oneonta.

Still, Bond says she worries that public opinion will hamper her departments ability to prepare for the future. What I worry about is the fatigue, the kind of mental fatigue of Covid, she adds. We can't let our guard down.

***

Before Christmas, Barreto drives about 15 minutes to Oneonta to see his own doctor. Oneonta is the biggest city in six counties with 13,000 residents and has the closest hospital to Barretos home practice.

Barreto brings a list of questions, knowing how hard it can be to squeeze out answers from his doctor in the allotted 15 minutes. There are always two agendas. There's your agenda as a doctor, why you wanted to see the patient, he says. And then there's a patient's.

After his appointment, Barreto grabs breakfast and then heads to his first house call of the day. He says he enjoys making home visits like an old-time country doctor. He crisscrosses three counties to see patients, 50 miles in any direction, and gives them his cell number, encouraging them to call whenever they need him. He sees two or three people per daycompared to eight to 15 in former hospital jobs.

Barreto guides his minivan to the interstate and then climbs out of the valley to visit Al Raczkowski, age 88. A former combat medic, Raczkowski still struggles with PTSD, has partial heart failure and some dementia, and requires weekly visits from nurses and therapists through a palliative care agency.

The family has no yardthe hemlocks grow right to the door. Barreto knocks then peeks in. Raczkowski stands in his semi-finished basement wearing a winter coat. Hes not wearing his hearing aid so Barreto shouts: Al, is Maureen here? Do you know why I came?

Raczkowski sits down on a futon. You're here to check on me, he says. With that, Barreto gets to work. The room is crowdedfirewood and tools jumbled by a woodstove, cardboard boxes, cases of soda and seltzer. A miniature Christmas tree stands on one table, an unfinished instant soup cup on another. Barreto unearths a stool and sets up his laptop beside the soup.

Do you remember why were wearing these masks? Barreto asks. Raczkowski isn't sure. Remember about Covid? Were wearing these masks to prevent spreading disease. Raczkowski nods.

Maureen, Al's wife, appears and shuffles to a seat. For the next hour, the three converse as Barreto performs his examination, mostly asking Raczkowski questions that Maureen answers. How are things with the care agency? Without their help I dont even think we would be here, Maureen tells him. Living on this mountain for 76 years. The nurses give Raczkowski showers, check his blood pressure and vitals, and keep him company.

Barreto asks how the medication is going. Its OK, Raczkowski says, but youd do better with a bottle of brandy.

Maureen complains about her husbands other health care. She drove him 80 miles to the Albany VA to try his new hearing aid, only to learn it had been mailed. As for the new psychiatrist? She closed our case, Maureen says. An appointment scheduled for September never happened, she adds, and no one ever answered her phone calls.

After Raczkowskis appointment, back in his car, Barreto vents frustration: If you look at a hospital system, and you count the number of medical personnel, versus the number of administration, there's a skew that shouldn't be there. All that oversight, he adds, doesn't help your relationship with your patient. It doesn't help them get the medicine.

Then he winds back down the mountain road to his next appointment.

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On Three Different Continents, Rural Health Strains under the Weight of the Coronavirus - Scientific American