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Hindsight: Dartmouth Researchers Reflect on Rural Health in the Pandemic

Dartmouth College
Elizabeth Carpenter-Song (L) and Anne Sosin, Professors at Dartmouth College

As we approach the end of a tumultuous year, NHPR is checking in with people we spoke to early on in the pandemic to see how things have changed. It’s part of a series we’re calling “Hindsight.”

Earlier this year, some doctors feared rural areas would be overwhelmed with too many COVID-19 patients and too few resources. In June, we reported on a study that found rural areas of New Hampshire and Vermont were doing better than expected - but things have changed quite a bit since then. Recently NHPR's Peter Biello spoke again with Dartmouth College Professors Elizabeth Carpenter-Song and Anne Sosin.

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This has not gone the way you predicted back then. Things look very different now. What has surprised you the most, Elizabeth?

Elizabeth Carpenter-Song: I think what we're seeing now, certainly at this stage in late fall and early winter, we're really seeing a divergence in terms of state responses between Vermont and New Hampshire...In the early days of this work, both states looked remarkably similar, and now we're seeing dramatically different state-level responses, which we believe are contributing to different outcomes across Vermont and New Hampshire.

Which ones would you identify? Which policy and which outcome?

ECS: We're really seeing the differences with the Vermont response being very robust at the state level. Early action...particularly some of the changes with respect to limits on social gatherings, for example, whereas on the New Hampshire side, we were the last within the New England region to issue a mandate [for masks].

New Hampshire has a political culture that emphasizes local control. What has the impact of that culture been on the pandemic?

Anne Sosin: One thing that's really important to understand in the context of the pandemic is the state response to COVID-19, including its contact tracing, is centralized in Concord. And this has important impacts on rural epidemics. We've seen a rapid growth in cases in southern New Hampshire impact the ability of rural settings to trace cases early on and this is allowed outbreaks to grow more quickly than they might have had contact tracing capacity been sufficient.

To add to that, we have seen growing outbreaks across rural regions, but we're also seeing really effective local responses in responding to those outbreaks. And those responses have really largely played out without strong public health measures at the state level and without strong outbreak response teams like we're seeing on the Vermont side of the river.

But what we really need to understand is that many of the public health measures that were in place in the spring and contributed to the state's early success are no longer there. And so while a mask mandate may have some impact on transmission, it's probably not going to be enough to reverse the trends that we're seeing right now. 

So when you say the systems that were in place in the spring are no longer in place, what do you mean?

AS: In the spring, the state was under a stay at home order, so there were significant restrictions on public institutions, the private sector, and on other areas of life. And now the state is largely open, with some limited restrictions. And that's quite different from where Vermont is as a state. Vermont has significant restrictions in place, some of which were already in place prior to the recent uptick in cases, and others which were layered on top of those public health measures. 

And Elizabeth, what does all of that mean for rural health specifically in New Hampshire moving forward?

ECS: In our early phase interviews in the spring, our interviews with health leaders really spoke to the rapid transition that these health systems had to take with respect to responding to the pandemic, scaling up their resources, thinking about how people would be shifted into different roles and preparing for the surge. What we're hearing now in terms of the rural health system is really...there's growing concern, of course, about the increasing cases within the region and specifically on our critical care capacity and on the rural health workforce as well.

One thing that I think is important for us to understand is that, as a region, we might think about the rural health system as being an ecosystem of care - and so what's occuring, for example, in the southern tier of New Hampshire has an impact on our rural health system. As those hospitals begin to reach capacity, then the ability of small and rural hospitals to transfer patients to those hospitals becomes very limited. And, of course, this is not only important for those patients who may be suffering from COVID-19 in rural regions, but also, for example, if one were to have a heart attack, the ability to get an intensive intervention can be compromised in this situation. 

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Peter Biello is the host of All Things Considered and Writers on a New England Stage at New Hampshire Public Radio. He has served as a producer/announcer/host of Weekend Edition Saturday at Vermont Public Radio and as a reporter/host of Morning Edition at WHQR in Wilmington, North Carolina.
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