The headquarters of the Kentucky River District Health Department sit up a curved, no-outlet street called Gorman Hollow Road.
From this hill over Hazard, Kentucky River District Health Director Scott Lockard coordinates the coronavirus response for seven counties in Eastern Kentucky.
As director, Lockard is the incident commander overseeing the scene of a nearly 10 month long medical emergency. Instead of a plane crash or natural disaster, it's a global pandemic that has stretched public health resources thin.
Public health experts have feared the outbreak of a highly contagious virus, and once the coronavirus began making its way into the United States, Lockard knew if the virus ever took hold in his district, it would be deadly.
People in rural areas like the Kentucky River District are typically sicker, older and have less access to regular healthcare than other communities.
They suffer from more comorbidities that make one more vulnerable to the virus, should they catch it.
“We knew that if individuals contracted COVID-19, that they were much more likely to have a negative health outcome because of these comorbidities,” Lockard said. “And that's what we've seen.”
The data so far has borne that out. Cases didn’t really pick up in his region until late summer, as Lockard recalls. But as of December 18, the district has seen 5,063 coronavirus cases and 56 deaths.
The death rate in November was 107% higher for the Kentucky River District than for the rest of the state. During that same period, the Kentucky River District death rate was 110% higher than that of Jefferson and Fayette counties, Kentucky's largest metro areas. November deaths in the district made up 4% of the state total despite the district having only 2% of the population. Out of 120 counties in Kentucky, only 18 had higher death rates in November than those comprising the Kentucky River District.
The District
One way to get to the Kentucky River District from the west is to take the Mountain Parkway.
It’s a scenic drive that leads from fields of central Kentucky into the Southern portion of the Appalachian Mountains.
It’s also one way to the Red River Gorge, a hiking and climbing tourism hub, and passes by the Natural Bridge State Park in Wolfe County, where Lockard was born and raised.
What you don’t see, Lockard says, is the declining health of people living nearby by the time you get to Hazard.
“From the time you got on the Mountain Parkway, to the time you got off the Mountain Parkway average life expectancy had dropped 10 years on that drive for people in those communities,” Lockard said.
Hazard is the county seat of Perry County, where the average life expectancy is 70 years, compared to 75.6 years statewide.
The district, like most of the rural United States, lag in nearly every data point used to measure the health of a region, with stubbornly high rates of smoking and drug use accompanying limited access to exercise and healthy foods.
Those all contribute to an increased COVID-19 death rate.
Lockard started his public health career at the Kentucky River District back in the 1990’s, when public health was expanding. Back then he visited pregnant women in the area and connected them to prenatal care and the Kentucky River District Health Department was 350 employees strong.
For a time, he was the public health director in Clark County, just east of Lexington.
“I had as much tax revenue in Winchester, in Clark County, to run one local health department serving 38,000 residents as I do to run a health department serving seven counties and 95,000 residents now,” Lockard said.
Lockard has been the public health director in the Kentucky River District since 2018, where he oversees a much smaller staff of 100. Instead of frequent in-home visits to pregnant women, as Lockard did early in his career, his department is more focused on public health initiatives, such as a recent successful push to pass a county-wide smoke free ordinance in Knott County.
The comparative resources of the two departments demonstrates what Lockard means when he says that public health is funded “the exact opposite of the way it should be funded.”
Kentucky’s local health departments are funded through property taxes. As the coal economy bottomed out in eastern Kentucky, so have property values and tax revenue.
In Kentucky, small, local government programs have been paying more into the state’s troubled pension fund than they could afford, and the operational budgets of local health departments have suffered.
But the problem is not unique to Kentucky. Public health budgets are shrinking nationwide, according to Ty Borders, director of the Rural and Underserved Health Research Center at the University of Kentucky.
The role of the public health department shifted over the past twenty years to provide fewer direct services to policy and informational campaigns, which require fewer investments in things like laboratory access or specialized training.
The shift is in response to shrinking budgets and also the fact that, because of the Medicare expansion, more people could afford insurance through the private market.
The coronavirus has called upon public health departments to do more than ever before, and says the public health response to the virus has ”pretty much uniformly across the states, been a failure.”
“The public health system has known for a long time that these types of infectious disease issues could be a problem,” Borders said. “But most of the public health system is really focused more on chronic disease or trying to prevent heart disease or trying to get people to stop smoking.”
Dealing With The Virus
Lockard and other local public health officials are now in charge of tasks like issuing citations to enforce health rules and contact tracing to limit the virus’ potential spread through the community.
Lockard says his department wrote 11 citations the weekend before December 7 for businesses who weren’t complying with public health orders. Beefing up the department’s contact tracing capacity has been a different challenge.
Reliable Internet service is harder to come by, and the state’s Kentucky Wired is the only option for most of the area.Contact tracers may need to cover multiple counties and hundreds of miles for door-to-door visits when someone can’t be reached by phone. Lockard’s district is 2,000 square miles; 89 miles from the county seat in Whitesburg to the county seat in Campton.
The Kentucky River District counties are also some of the poorest in the state. Expanded unemployment benefits are set to expire on December 30 along with other federal stimulus programs, so Lockard says people may be reluctant to disrupt their work lives by getting tested after learning they’ve been exposed.
“It's very much a financial decision,” Lockard said. “Because they it's a financial burden on themselves and their families.”
The Kentucky River District has hired 14 additional contact tracing staff using federal CARES Act funds, stimulus money that is set to run out on December 30.
The new coronavirus relief package passed by Congress on December 21 allocates $20 billion to states to help fund contact tracing and testing, though President Donald Trump has suggested he may not sign the bill into law without major changes.
Deirdra Robinson is a social worker and professor at Morehead State University who, thanks to the CARES Act, has been working with the Kentucky River District contact tracing team since August.
From Perry County, most of the contact tracing team onboards potential new cases into the system by recording names and contact information. New contact tracers work from Lee County, mostly because that’s where Lockard could find additional space.
The district had fewer than 40 cases throughout most of the summer, before things began picking up in August. New cases are popping up at a much faster rate. Robinson had input 68 new cases into the contact tracing system the morning of December 7 alone.
Robinson said folks were able to overlook the virus during the early months of the pandemic because cases were so low out in eastern Kentucky.
"Unless it's in my backyard, and I can point to something very personal, where I can say, ‘This person had this experience,’ it's really easy to say it's not going on here, that's in the big city, or that's in another state,” Robinson said.
Now, Robinson said the virus is impossible to overlook.
Lockard himself spent much of November quarantined after his daughter caught the virus at Morehead State University.
“My hairdresser had it, she went to a triathlon the week before, and she was too tired to get out of bed that week,” Robinson said. “You really can't predict the path of this thing. You just have to do your best.”
COVID-19 in Rural Hospitals
Now that the virus’ path has led to rural Kentucky, hospitals are feeling the strain of a contagious virus making its way through an already unhealthy population.
Rural hospitals are dealing with 10% more COVID-19 patients than they were in September. While the share of COVID-19 hospitalizations is declining in Kentucky’s large metro areas, it is still increasing in rural counties.
According to data released by the federal Department of Health and Human Services, 33% of recorded COVID-19 infections lead to hospitalization in rural Kentucky, a rate that continues to climb even as it declines in Kentucky’s large metro areas.
“In rural communities for the most part you’ve got poorer people, you’ve got sicker people, and typically the average age of a person out in a rural community is older,” said Elizabeth Snodgrass is the Chief Executive Officer of the Livingston Hospital in western Kentucky.
As a federally-designated Critical Access Hospital serving an area that would otherwise lack a hospital, Livingston Hospital does not have an Intensive Care Unit. They’ve developed a resource sharing network with eight other hospitals in the area, including one in Southern Illinois, to send critically ill patients to larger hospitals.
Snodgrass says the hospitals are seeing more and more coronavirus patients.
“And it’s not just that they are COVID positive. They are very, very sick. They are on ventilators,” Snodgrass said.
Livingston Hospital is currently 57% full, according to the federal data, and Snodgrass said that cooperation has helped relieve some of the pressure.
But back in April, when coronavirus cases were much lower than they currently are, the hospital saw how disruptive the virus can be. Seven members of the hospital’s nursing staff caught the coronavirus and had to stay home from work at the same time.
Already short staffed, Livingston Hospital had to reroute patients elsewhere.
Last month, Snodgrass and other hospital leaders in the region sent a letter to members of the community, asking the community to help them by wearing masks and social distancing to keep cases numbers low.
“That's all we know at this point,” Snodgrass said. “It's to wear a mask, wash your hands and distance yourself from others in public.”
Data scientist consultant Mike Shumpert, working in coordination with the National Press Foundation, contributed to this story.
Correction: Deirdra Robinson is a social worker and professor at Morehead State University. The university and spelling of her first name was incorrect in a previous version.
