Episode 23: Covid-19 in rural communities: The emerging story

July 29, 2020

Note: With our recording studio on the USM campus closed, we will be posting episodes using the “live” audio from our new Covid-19-focused Greater Good webinar series. You can find out when the next Greater Good webinar is by visiting our Events page.

 

Covid-19 media headlines are often centered around large, urban areas, but rural communities are facing unique challenges in combating the pandemic. To discuss these challenges, we talk with three Maine healthcare and public health experts with a long-standing interest in re-visioning Maine’s public health and rural health systems. They will discuss the rural health challenges before the pandemic hit, what is happening now in rural healthcare and rural economies, and where we can go from here to create a brighter rural future.

 

If you would prefer to watch the webinar recording of this conversation, you can find it here.

Also available on:

 

Notes

 
Episode Notes

Covid-19 media headlines are often centered around large, urban areas, but rural communities are facing unique challenges in combating the pandemic. To discuss these challenges, we spoke with three Maine healthcare and public health experts with a long-standing interest in re-visioning Maine’s public health and rural health systems. They discussed the rural health challenges before the pandemic hit, what is happening now in rural healthcare and rural economies, and where we can go from here to create a brighter rural future.

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Produced by the University of Maine Graduate and Professional Center, with help from WMPG

Episode Guests

Dr. Erika Ziller is the Chair and Assistant Professor of Public Health at the University of Southern Maine’s Muskie School of Public Service, where she teaches courses on health policy and the U.S. healthcare system. She is also the Director of the Maine Rural Health Research Center, and has directed numerous studies on rural health access, coverage, and health reform. Dr. Ziller has served on the editorial board of the Journal of Rural Health, and has won national awards for her contributions to this field.

Deb Deatrick is a part time public health consultant who retired in 2019 from 20+ years as the Senior Vice President for Community Health Improvement at MaineHealth, the largest health system in Northern New England, which includes Maine Medical Center and eight community hospitals, mostly in rural areas of the state. Her career spans 30+ years in public health and includes eight years in the state health department as the Director of the Office of Dental Health, as well as teaching, research, and advocacy.

Lisa Miller recently retired from her job of 20 years as a Senior Program Officer of the Bingham Program, a Maine health endowment based at Tufts Medical Center in Boston, where she focused on health care, public health policy, and community health. Lisa also served in the Maine House of Representatives for six years, representing a district of five small rural towns. She was a member of the Legislature’s Appropriations Committee as well as the Health and Human Services Committee.

Disclaimer

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Transcript

​This transcript has been lightly edited for clarity.

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The Greater Good: Episode 23

Rebecca: Okay. Let’s get this party started. Hello, I’d like to welcome you to our second Greater Good webinar, a spinoff of our greater good podcast series on Covid-19. Media headlines are often centered around large urban areas, but rural communities are facing unique challenges in combating the pandemic. To discuss these challenges, I’m joined today by three main healthcare and public health experts with a longstanding interest in revisioning Maine’s public health and rural health systems. We will discuss the rural health challenges before the pandemic hit, what is happening now in rural healthcare and rural economies, and where we can go from here to create a brighter future.

I’m Rebecca Gilbert, program coordinator at Maine Center Ventures, or MCV, and I will be moderating today’s discussion. MCV is non-profit that supports the development of the University of Maine Graduate and Professional Center.

Today, I am pleased to welcome our three guests. Dr. Erika Ziller is the Chair and Assistant Professor of Public Health at the University of Southern Maine’s Muskie School of Public Service, where she teaches courses on health policy and the U.S. healthcare system. She is also the Director of the Maine Rural Health Research Center, and has directed numerous studies on rural health access, coverage, and health reform. Dr. Ziller has served on the editorial board of the Journal of Rural Health, and has won national awards for her contributions to this field. Deb Deatrick is a part time public health consultant who retired in 2019 from 20+ years as the Senior Vice President for Community Health Improvement at MaineHealth, the largest health system in Northern New England, which includes Maine Medical Center and eight community hospitals, mostly in rural areas of the state. Her career spans 30+ years in public health and includes eight years in the state health department as the Director of the Office of Dental Health, as well as teaching, research, and advocacy. Lisa Miller recently retired from her job of 20 years as a Senior Program Officer of the Bingham Program, a Maine health endowment based at Tufts Medical Center in Boston, where she focused on health care, public health policy, and community health. Lisa also served in the Maine House of Representatives for six years, representing a district of five small rural towns. She was a member of the Legislature’s Appropriations Committee as well as the Health and Human Services Committee.

I want to highlight that each of them is trained in public health but none of them are epidemiologists or infectious disease experts!

At the end of today’s discussion with our guests, we will save some time for questions from the audience. Please feel free to submit questions using the Q&A feature at the bottom of your Zoom window.

Erika, Deb, and Lisa —welcome to The Greater Good!

Guests: Hello.

Rebecca: We’ll be talking today about some of the unique aspects of rural places that may make them vulnerable to COVID-19. To set the scene, I want to start by talking about health in rural Maine before the pandemic started. Deb, would kick us off?

Deb: Sure. Just a couple of quick comments about that. And as you point out, many of our rural communities, we’re really struggling with a number of health challenges way before Covid- 19 hit, as I like to say. Just a couple of background points I want to make. There are a lot of different ways of measuring health. You can do big population-based surveys. You can look at clinical data, you can look at the cost of care that’s being provided. We look at all of those things here in Maine. There are a couple of reports that I have used for many years that I think are really helpful. One is called America’s Health Rankings that compares the health status of every state in the United States. It’s a report that comes out once a year. This past year, Maine was number 21 out of the 50 states. Not a very good ranking overall. And in fact, our overall health status hasn’t been great for some time. Interestingly, Vermont this past year was the healthiest state in the United States. Which is interesting because our demographics are very similar to Vermont. Though there’s a number of questions there about why that is the case. And then there is another report called the County Health Rankings that actually ranks, and again, each of these reports looks at about 40 different indicators, everything from clinical care to air quality, et cetera. The county health rankings ranks every county in the United States, and again, all 16 Maine counties. Cumberland County was the healthiest county in the state this past year. Washington County and some of the rural counties tend to be less healthy. However, it’s not necessarily a predictor. You will have a rural area that you are going to be one of the less healthy counties in Maine. Knox and Sagadahoc, and Hancock County were all very, very high up in the rankings this past year. And the reports are, are useful even though some people find them to be kind of stigmatizing. They’re really a call to action for local groups and have been used in that fashion for many, many years. So again, we may have some questions about what’s in those rankings and why we do the rankings later on. But that just hopefully sets the stage a little bit. Again, Maine was named number 21 this past year. If you look at a composite of the entire state,

Rebecca: So Deb, could you talk a little bit about why the numbers look that way and how that might affect risks for Covid-19?

Deb: Yeah, absolutely. First of all, as I often point out, there are basically four main buckets of factors that affect health. The first one, and many people think this is the, you know, the biggest one is clinical care. We have great hospitals in Maine. We have great health centers, we have great providers, et cetera, that in the whole scheme of things, clinical care accounts for only about 10% of health. The biggest predictor, the biggest bucket of factors are behaviors, that account for about 40% of overall health status. Community and environment about 30%, and policies about 20%. And I mentioned this in response to your question, Rebecca, because if you look at the kinds of things that are looking to be most predictive of Covid or the severity of Covid in addition to viral load and those kinds of things. They are race and ethnicity, age, gender, and access to health care. And then other factors which are looking very much as if they have an impact or things like housing and employment. And obviously your economic status, where you work, where you go to school, how many people you live with, et cetera. So we know a lot about what creates health encoded in the time of Covid. We are learning a lot and we have a lot to learn, frankly, about how these big buckets are affected by the other kinds of factors that seem to be more associated. I will say that in rural areas, you know the whole issue and we’ll talk about this a little bit later. Social isolation is a huge issue for people in rural communities. And that can mean everything from not getting adequate health care to not having conformation, you know, all kinds of things. So I’ll let it go at that. But we, I think the most important thing is that we are just in the first part of the learning curve about What does impact Covid risk factor perspective.

Erika: If I could jump in, I would like to pick up on and go back to your point about economic hardship and their relationship to health. And we know from studying rural health that there is a really key interplay between economic health and the physical and mental health of communities. And this plays out in a whole variety of different ways. For example, rural communities across the country and also in Maine, can sometimes face challenges in terms of the availability of jobs or in jobs that pay really well or are stable. So we in our rural communities were more likely to see some seasonal employment, et cetera. And all of these things can really compound to create less access to health insurance. Since so much of that as saying historically job based in this country and therefore less access to care as well. And you know, there have been some studies that look particularly at the impact of the Great Recession on that health and well-being of rural populations. And found that there was an extreme, not extreme, but a marked increase in what the researchers called deaths of despair. So things like deaths from substance use disorders or from suicide, or liver disorders from, from chronic drinking, et cetera. And while there’s a lot of questions about causal relationships Et cetera. It’s definitely clear that when rural communities are not thriving economically, it’s really hard for them to be thriving in terms of their health and well-being as well. And that plays out in a whole variety of ways. From the social social isolation that Deb was talking about to issues of transportation, housing, food access, and all of those we’ve seen are really intimately intertwined with Covid-19 issues as well.

Lisa: You know, I’ll jump in too. I think a lot of that is beginning to be reflected in rural healthcare systems. I think rural hospitals in the past decade have started developing much broader and deeper relationships with their community partners. In recognition of some of these social determinants, I think we’re seeing those kinds of collaborative efforts out in western Maine with Healthy Oxford Hills or Coastal Maine, Healthy Acadia, and Mount Desert Hospital. And more and more those are, I think bubbling up from a history of 20 years ago, I think of, of a lot of coalition development called Healthy Maine Partnerships. But rural healthcare systems are facing their own issues, as we all know. And Covid has just sort of blown that up. I mean, that the financial systems for rural hospitals were fragile before Covid came along. And then when they had to regear, eliminate elective procedures and things to kind of prepare for Covid their financials took a real dive. Primary care has also been a problem in rural areas. Hard to recruit primary care clinicians and hard to hold onto them. So that healthcare system in rural areas started out being fragile and Covid is making that, I think, even more of an issue.

Erika: Those are all great points, Lisa. And they really, I think, illustrate another way in which the economic systems in a community and the healthcare systems are intertwined. So to your point about recruiting health professionals, that can be challenging to do when, you know, there, there were not a lot of amenities. And a community when the community’s not really thriving, when it doesn’t feel like there’s a lot happening in the downtown. It can be harder to sometimes get rural physicians or nurses to come and join that community so that there’s a trick there. It’s also hard for the hospitals to stay afloat when the community is in it. Economic model and maybe losing health insurance, a hybrid lot. Reliance on Medicare and Medicaid can be challenging for some hospitals to make ends meet. So, you know, when, when your community is in a slump, it’s hard for the hospital to be vibrant. And it’s also hard when your community is not super healthy, when you’re not doing well. On some of those indicators that that talked about earlier, to recruit new businesses to that area and to build it up and operate in that way. So it’s definitely a two way relationship.

Lisa: I think hospitals had been hustling to respond to this. And I think we’ve all seen the huge trend towards consolidation – rural hospitals joining larger networks that help them stay afloat financially, help them recruit specialists, help them maintain certain kinds of services, and help them even just sort of be part of purchasing alliances, et cetera. It comes at a bit of a cost. I live in Lincoln County and it was very controversial when the Boothbay Hospital was closed, the community felt like they were not being heard, et cetera. You know, when you seemingly loose your local community hospital, it has, I think, an emotional impact on communities. But an interesting sidelight to this integration and consolidation is I think it has benefited Covid planning. I think it has helped small rural hospitals be part of a larger network to kind of gear up for present and future hospital threats from the Covid pandemic though.

Rebecca: You’ve each highlighted ways that rural economic and healthcare infrastructures are challenging and can affect people’s health.  Where does the public health system fit in here and what are the COVID-19 Implications?

Lisa: Well, Maine has a very unusual public-health system. We do not have a system of county health departments like most of the states. We only have municipal health departments. We do have, and I was one for 20 years, Local Health officers appointed in our small towns. Sometimes they are the code enforcement officer, sometimes the dog catcher. You know, they’re not always people who might have background in that area, but we do have them. And, and they do have an assertive, circumscribed responsibility. We have a very state-based system that has a lot of responsibility based in Augusta. Unfortunately, in the last administration, there was some real intentional reduction of that system. And we lost, for example, for rural areas, we lost a lot of public health nurses out, out in our small towns. And that’s where rural Maine. So to saw public health at work for quite a while. So we’ve lost a lot of coalitions through funding cuts. We’ve lost some chronic disease programs and, you know, a number of contractors were greatly reduced. So that plays out with Covid. I think we saw last time we had an epidemic to H1N1. A number of these coalitions were called into action to help the public education outreach, even, I believe some vaccine programs this go around. We don’t have that articulation between the state and the local as, as strongly. And some of those resources are gone. So we do have a new administration. They, they are committed rebuilding public health. But it’s going to take some time. And Covid has certainly shown that we’re not there yet.

Deb: I’d just like to echo a couple of things that Lisa mentioned. I’ve been in Maine for quite a long time and we do have a great tradition of forming coalitions and local organizations. And still today, even though that Healthy Maine Partnerships are a thing of the past, there are a number of coalitions that are connected to hospitals. Some are independent. 501(c)3s that are extremely active in terms of and in many ways are the local public health infrastructure in this state. And examples, as I mentioned, Healthy Oxford Hills, the healthy community in Oxford County that’s connected to Stevens Memorial Hospital. The Healthy Community Coalition in Farmington that’s connected to Franklin Memorial Hospital. Healthy Acadia is a independent, but I know it has a close relationship with MDI hospital, the Healthy Communities of the Capitol Area Coalition that works very closely, I know with Maine General and other healthcare organizations. So this is having this kind of very close relationship is a huge leg up. When we get into a situation like Covid, hospitals typically don’t have the personnel. They don’t have the training. They don’t have the time to go out into the community to forge those important relationships, to be able to do public education, to engage other partners, et cetera, et cetera. There are and I, by the way, I know I’ve left out some of the important coalitions in the states. I didn’t mean that to be an exhaustive list by any stretch of the imagination. The Maine DHHS a number of years ago, began making frequent under the preventive health services umbrella. Is also supporting somewhere between 2030 local organizations around the state for tobacco, obesity, substance use disorder, activity. So it’s a very strong network and that is statewide. The other thing I’ll just mention is that increasingly hospitals are being touted or characterized as so-called anchor institutions in their communities. Why? Because they are not-for-profit. They obviously have a lot to give back. They do give back to the community in many ways. But there is a national network that was formed several years ago called the Healthcare Anchor Network. And now hospitals and health systems across the United States are sharing approaches and ideas. Investing in housing, investing in food security networks investing, and transportation systems, et cetera. They’re going beyond our four walls and that narrow definition of clinical work to really recognize, can frankly makes a major investments in these kinds of resources in the community, which is really good news. And that is definitely happening here, and Maine as well.

Rebecca: So, essentially, pre-COVID, rural communities had some serious economic challenges that were affecting community members’ health and vice-versa. We also saw some promising public-private partnerships that were developing or rebuilding. But then March happened. What do you think some of the effects of COVID-19 have been or might be?

Erika: It’s a great question, Rebecca. So I would say that initially, I think that Covid was, I wouldn’t say in an afterthought for world places, but it didn’t feel quite as urgent concern because so much of what we saw unfolding in the early weeks and months of the pandemic were taking place and are much more urban populated areas contrary so on New York City’s New Jerseys, California, etc. So we were, I think experiencing very similar types of things here and mainland and prep for the most part up until this point. So Cumberland, York counties are the most affected by Covid right now and have been throughout since March. Some areas of Androscoggin county. Some zip codes in Portland and Lewiston have some of the highest per capita rates of infection. And I think that’s obviously incredibly good news for our rural places. We hope that it does not spread any further and that we’re able to reach great containment in both our urban places and don’t seem much rural spread. On the other hand, this could lead to our rural areas maybe not fully appreciating or understanding the risk of the pandemic and how it might eventually come home to them in ways that could be really upsetting. And no, I don’t want to say cataclysmic. Cataclysmic. I don’t want to be an alarmist or anything like that, but could be serious. So for example, there are small counties in Texas, one, for example, where in June they had 30 cases of Covid and then suddenly they had thousands because it was introduced into their community and across the whole country. A lot of the world’s spread of Covid the rural outbreaks have been in places like nursing homes and, and that’s kind of what we’ve seen so far and not a lot of community spread, but it is possible. And some of the earlier communities that were hardest hit by Covid were a few rural towns in really high touristy areas in Utah and Colorado. Lots of people going there to ski, etc. And they ended up with some really serious outbreaks. And those communities, and it’s been challenging with than some of the hospitals and healthcare systems in places like Texas, or really scrambling to meet the health care needs of their communities as a result. And in thinking about rural, it’s also really important that we don’t forget our indigenous and tribal populations. And you know, they, they certainly at this point also seem to be at, at lower risk. We haven’t seem serious. Spread into our tribal communities adds up now, but in other parts of the country they have, and the rates of infection and serious consequences have been pretty bad. And some of the reservations and other indigenous land. So it’s something we have to be mindful of and make sure that we’re not being too complacent.

Deb: I’m going to just pick up on that word for a minute, Erika, complacency. It’s interesting. I just looked at the statistics yesterday on a county by county basis for the number of cases across the 16 counties of Maine. And we have counties like Washington County with four cases to date and Pisquataquis county with five, and obviously all the way up to Cumberland County with almost 1900. So there are some very huge variations across the state. And it’s understandable as to why people who live in rural areas of the state, even rural areas of Cumberland County, potentially, you know, think that it’s not really an issue and is not going to affect them. And I think it is, you know, unfortunately, we have some factions of our society that have declared to be anti-science. There are many conspiracy theories that are around in terms of where the virus came from and why it is circulating in certain communities, et cetera, which is really very not helpful obviously to our efforts to try to contain the virus. And I do, even in very rural areas where there are very few cases, you know, the, the basic three recommendations, you know, public education about the virus and about how to protect yourself. The need for masking when you go out in public and the issues of social distancing are really relevant to any population. And we think we’re doing a pretty good job here at the state level. I do want to call out just as one example, the folks in Bar Harbor have done, I think, an extraordinary job of working together, the community, the hospital, healthy Acadia, et cetera, whether it’s resources for getting people to testing. There’s a lot of public education. Employers have been very engaged. I talked to a friend who spent the weekend in Bar Harbor who said that virtually everyone was masking. I haven’t been there myself, but that was good news. So I think there are many things that can, can be done. We really have to pivot away, I think, from blaming people, blaming organizations, blaming political parties or political leaders, et cetera. And listen to our public health experts. We have some great ones here in Maine. Doctor Shah, I think, has done an extraordinary job informing the public on and really helping us to not only flatten the curve, but really to focus on masking and social distancing, et cetera.

Lisa: Well, I think there’s sort of cause for complacency in rural areas because the numbers right now are set low. But I gotta tell you, the healthcare system hasn’t been complacent by any means. And the rural hospitals had been easy and at their own peril, they’ve, you know, as I said earlier, a number of them called off elective procedures so that they could start restructuring their beds. Many have created more ICU beds, many have created more infection friendly rooms. Many have restructured their ERs to prepare for more infectious cases. So I think, you know, hospitals have really been gearing up for this. So have medical practices. And I do recall early on, my husband’s a rural physician now retired but works in some health centers that they, you know, they called off a lot of elective appointments as well to, to kind of prepare for more testing and infectious arrival. So the healthcare system, I think, has really been mobilizing for this. I think they’re fairly ready. It looks like we have sufficient ICU restore axes out the air and rural areas. There are questions still about supply chains of PPE materials, testing materials, et cetera. So we’re not totally perfect, but I think we are pretty, we’re well along our way to respond to an outbreak that might flare up in rural areas. There is still, I think, better communication that needs to happen between, let’s say a health department people and medical people. And that I think is improving. And the health department’s doing a terrific job. But we’re all learning as we’re going along with this. But I’ve been really impressed with the rural healthcare response.

Erika: So I definitely like to echo what Deb and Lisa both said in terms of the numbers driving a lot of this complacency. And complacently isn’t the best word. But this sense that maybe the risk is not as a Covid workplaces because that’s what we’ve been seeing in the numbers for sure. And so that also I know and have heard we’ve cause a tremendous amount of frustration for people in terms of what that economic impacts. And so I think, you know, Covid has absolutely illustrated again, how important that link between health and economic vibrancy and well-being really are, and how fragile some of those connections can be. So across all our communities. And may we had seen terrible job losses, layoffs, or furloughs. Workers, people are struggling with housing issues, struggling to pay rent, struggling to cover mortgages. Schools shut down, and schools can be a really important first line of resources for some of our most vulnerable community members – children. And that’s where they often get a couple of their solid meals for the day. So having that food, that food access affected food banks have been struggling. They’re really over packed. So all of these things are coming in. This second wave of consequences And when we look at at how it’s affecting our rural communities, we definitely have a reason to be concerned. As of June, the country, the counties, and Maine that had the highest unemployment rates. The first three were our rural Western and Central counties and then followed by Cumberland and we have reason from prior economic down turns to really think that the, the urban ones are probably a shorter duration than urban areas tend to bounce back from recession’s a lot faster than rural areas. Just by nature of their, their economic base. And all of this loss of connection to employment is also a potential loss of connection to health and trade. Since that’s where so many of us tend to get our friends. And, and so that’s also a concern. We still don’t know what the long-term impacts are going to be on health insurance coverage and this in the state and in our rural communities. I think it’s really fortunate that we expanded Medicaid may care when we did because they are catching a lot of people who might otherwise be going without coverage. And that’s super important. And then, and of course, tourism, and what the impact of all of this is going to be on tourism is really honestly frightening for our rural communities. It’s a huge industry statewide. So many of our rural communities depend on these dollars for their, you know, the summer dollars in particular for the rest of the year. And so figuring out how to balance safety and the need for those out of state dollars is a really complicated and delicate dance. And I love the examples that gave about how they’re making that work. Then obviously, as we already noted, rural hospitals really are economic drivers or communities, and a lot of ways a number one employer. And so we need to keep an eye on them and make sure that the policies and responses to Covid are keeping them protected.

Lisa: We’ll just add a little bit. I mean that the interplay between economy and Health, I think we’ve pounded you with that now in this program, but that sort of symbiotic relationship between private sector medicine, and government public health has really become quite evident in this Covid era. And we’re going to need stronger surveillance systems between our private sector medical groups and government public health. We’re going to need probably more discussions about surge preparation. If a vaccine truly becomes available, we gotta mobilize. Some screening, excuse me, some vaccine clinics, perhaps that is a probably a very strong public private partnership. So that’s what makes Maine interesting and unique. I think in, in the, in the the marriage I think of the private and public sector around public health.

Deb: Absolutely. I’ll just quickly point out that again, where there are relationships in the community already, that’s strong network between a health care provider, could be a rural health center, could be a small hospital, and community organizations. We’ve seen the need for food, food access be a tremendous issue here all over the state, particularly in rural communities and hospitals and health centers that were already have relationships. And even some of them providing actual food backpacks to students and to patients are going to be in a much better place. And, and believe me, I think none of us believe that this is the only time we are going to be experiencing something like the Covid pandemic. I think it is just a harbinger probably of things to come.

Rebecca: Great, thanks Deb. It sounds like these partnerships are a critical part of Maine’s solution to the health and economic challenges from Covid-19, both now and in the future. What else do you see as bright spots for Maine’s future? And what are the risks you’re seeing?

Erika: At the risk of sounding too gloomy, I would say there are definitely some bright spots, but also some risks that we need to be cognizant of. We are certainly early, even though it feels like we have been at this forever, we are still pretty early in this pandemic and we don’t entirely know as much as we need to about the virus, what its long-term impact will be on the people who contract it, what the impact will be on names, economy. And so much of that is going to depend on having really strong, solid public health and policy responses that are cognizant of our world pieces and really make an effort to ensure that, that they are being protected and that resources are getting to that accordingly. I think that’s absolutely critical.

Lisa: I think we always start with the bad news and then maybe head to the good. But I, I am still concerned about the sort of second wave and how that’s going to play out in particularly in rural areas. And I think we’re mobilizing well for that. But as we know, are populations in rural areas, do you have a higher burden of chronic disease? And I think there was a question about that in that people have of in a sense, avoided some care or been denied some care for various kinds of chronic diseases because of preparation for Covid care. And I don’t have any data about that name, but I know that has been a concern of clinicians that, you know, the number of elective visits both in primary care and in the hospital have dropped way down. And those are important secondary and tertiary prevention visits for people with chronic disease. So that, that could be a double whammy in, in rural areas. And I welcome any if anyone has any data on that out there. It is a big concern that the upside is I think maybe Erika kind of pointed to this. I think that this event is illustrating to us how important public health is to the common man, to the common person in Maine that we may want and need more, more local infrastructure than we currently have. And we may want those links, you know, to be even stronger between community organizations and medicine. Check-ins on the elderly. I know a lot of groups are doing that. Public education around face masks. Hospitals don’t have time to do that. You know, small business assistance about how do you really clean up to be ready for customers? I mean, there’s, there’s a world of interaction around community health that needs to be done. And, and I think we’ve got people out there to do it. We, we, we need to, to mobilize them and connect them.

Deb: Yeah, Lisa, I think you’re absolutely right on with those comments. I read a report just yesterday about from a number of healthcare providers at the national level who are very concerned about individuals with chronic conditions delaying treatment, and in particular, people who have cancer, maybe delaying surgery, delaying radiation, delaying chemotherapy, et cetera. We’re already seeing a massive impact on immunizations, childhood immunizations in particular, It’s happening in the state and happening and other states. And again, as kids go back to school, there’s already efforts being made to provide immunization clinics pending schools opening in the fall to make sure kids, particularly kids in K through six, K through four, are fully immunized before they go back to school. So it’s you could call that a risk. I, I think it is something that we can’t even quantify at this point to the question that someone posed earlier. We do have good data about chronic disease incidence and prevalence and name. So that will give us, I think some The ability to predict exactly what again, as more as being known about the interplay between covert and chronic conditions. And again, there’s so much research that is going on right now that it’s honestly hard to keep up. But my favorite source of information is something called MMWR, the Morbidity and Mortality Weekly Report that the US CDC puts out. And if anyone, it’s free. You can subscribe to it online. And a lot of the kind of up to the minute research that’s going on with Covid appears on a regular basis. I’m hopeful about is that the issue of complacency, the kind of default that we’ve had not only in the United States, but just generally of people not to get concerned about anything unless it’s an emergency situation. You know, planning, long-range planning, emergency preparedness planning has never really been high. Anyone’s agenda, you know, there was some investment in that a number of years ago and we’ve kind of fallen away from that. So I’m hopeful that we will have learned from this that crisis mode is not the best mode to handle a pandemic. That we do need to, as Lisa mentioned, build infrastructure and maybe formalize some of the infrastructure that is in play currently. I think there are a number of policy initiatives that are going to come out of this. There’s already talk about some specific legislative initiatives that are going to be coming to the main legislature in January. One of I just want to point out that just before the I call it C day of March 13th, which happened to be a Friday, which we kind of look at as the day when things changed, not only here in name, but nationally, but definitely here in Maine. On March third, there was actually a referendum. Some of you may remember, it was a statewide referendum on a new, whether or not to repeal a new vaccine law that Maine had passed and last the prior year. And what was someone who worked on that campaign? I can tell you that I was incredibly, sort of positively surprised at the outcome. It was a three to one vote. People not only learned about herd immunity, that concept a learned about, you know, individual versus collective benefit from vaccines. And this was a very, very early days of the Covid pandemic. So I think there was a lot of learning that happened here in the state of Maine. Obviously, people overwhelmingly voted to keep that law in place. And I like to think that some of that public awareness and public education is going to carry us into this time of Covid. And hopefully as we approach, as Lisa mentioned, a vaccine, perhaps at the end of this year, beginning of next year, that the anti-vax movement is not going to resist. We are not going to, hopefully that will go away. But I think hopefully the education and the support that Maine people have already indicated for vaccines as safe and effective will, will help us as we go forward.

Erika: So totally anecdotal evidence on my part, but obviously we do, as Lisa and Deb both articulated it very nicely, I hope that this translates into much more support for public health and prevention. And in terms of positive signs of that, I can tell you that here at USM in our public health degree programs we are seeing record interest, particularly in our masters of public health. And that is only good news for this state. Having more locally grown and trained public health professionals. It’s just a win-win for everyone. And I would say back to your question about strengths and opportunities. Rebecca, one of the things that I’ve observed about Maine growing up in Western Maine Oxford County is that we have the most remarkable sense of community spirit and our ability to hold together as small communities, as towns and to work across all sorts of different organisational lines is pretty remarkable. I very much remember church dinners that were put on in support of family and squares. Someone’s mom was sick or somebody had lost their home where any tragedy happened. And it’s been very gratifying to see a lot of that playing out in our rural communities in terms of their Covid response. Whether that’s groups getting together separately to sew masks for health care providers and others, whether it’s people cooking meals for people that they know are really struggling to feed themselves. Some of those contracts that Lisa was talking about to reach out and make sure that are more socially isolated and vulnerable. Seniors have somebody to talk to you and are able to communicate about whatever needs might be met. All of those responses are so encouraging.

Lisa: I would say, I think we still have to recognize that some people are seriously left behind in all of this Covid work and response. And, and the, the sort of frightening and disturbing statistic about infection rates among people of color, particularly African Americans and, and immigrants 25-25, four times more likely to test positive. So there is a lot of work to be done and, and public health needs to respond to that. That is a frightening statistic. An upside of that is that there is quite a lot of mobilization going on among advocates and Augusta to start addressing some of that. And we, we had a question about infrastructure that popped up. And it’s a very valid, I think, criticism of what we’ve said so far in that there’s more to infrastructure than community coalitions. And that is definitely true. And now we have been focusing on rural areas and some, some of that infrastructure doesn’t always filter its way out to the small towns. But we do have district liaisons. We have epidemiologists, we have public health nurses, we have lab core based in Augusta. All of those are incredibly important for an infectious disease response. Some of those resources we’re trying to rebuild to be honest. But a lot of those state health department, Maine CDC employees have been swung into action on Covid. And they’re very important part of the infrastructure. And I think becomes more visible to the public about what, what public health is, what’s needed. So we apologize if, if we’re making it sound like they are not important parts of the system. They need all the support they can get to, to rebuild adequately for perhaps the next pandemic.

Deb: Yeah. I just want to quickly add Lisa mentioned we have to municipal I’d I absolutely underscore which she said we have to municipal health departments in the state. We used to have three. Actually, there was at one time one and Lewiston/Auburn. And they also deserve all the support and have a core of individuals who like the Maine CDC are working very hard in the community and don’t necessarily restrict their services and programs just to Bangor and Portland. That I just quickly want to mention that from my perspective, I think another positive out growth in addition to public recognizing what public health is and does is relationship building, et cetera. And that is the Black Lives Matter movement and the increasing cries for social justice that are growing out of the disparities in health data. It is a part of that. And I think it is the perhaps in some respects the tip of the iceberg. It is so important that we have better data. And that was also mentioned in one of the questions. We absolutely have to spend more money, more time, and more resources on gathering surveillance data, reporting surveillance data, and interpreting surveillance data. And again, that’s not only for rural areas of the state, but certainly with regard to vulnerable populations. It is absolutely critical.

Rebecca: So I’m conscious of the time, even though I’m sure we could fill hours and hours of content. Erica, I was wondering if you could kind of give us some of your thoughts on how the pandemic could be… So we just talked about Black Lives Matter is one area that we’re seeing kind of being illustrated in different ways. How else could this pandemic be affecting our thinking in our future approach to other problems that Maine is wrestling with right now.

Erika: Sure. I would say that I think that the first play is that it is made, laid bare and made so obvious connection between economic health and physical and mental health in Maine. And I’m hoping that people are policymakers, are now economic development and it occurs, et cetera, will be thinking of this and considering this much more holistically and in a more symbiotic way moving forward. I also think that there’s a chance, I mean, Maine’s economic challenges have been a lot of population loss in our rural communities and are really good numbers. And trends of Covid are making us an attractive place to consider relocating. And I know at least in part we’re seeing a lot of people from out of state, at least in my neighborhood and moving in, I can see that spreading to other parts of the state and being a real positive.

Rebecca: Yeah, it strikes me another way that we’re kind of seeing this play out is from a technology point of view. Today’s Election Day in Maine and broadband is actually on the ballot. Lisa, I was wondering if you could kind of speak about what is the role of broadband in the response to the pandemic but also other challenges that we’re facing in the state.

Lisa: I’d love to. I presently live in a little town of 500 people. I wasn’t sure that I’d make it through this presentation with my lousy broadband. And I’m only about 18 miles outside of Augusta. So I think this episode, it’s not even an episode, is going to be longer than an episode. This era of Covid, it really has pointed out some very interesting issues around broadband mean. There’s the whole sort of medical telehealth issue that if you can’t get in to see a specialist or get into your doctor’s office because you’re worried about Covid infection, you could hook up through telehealth. Telehealth also opens up a world of home visiting that maintains safety in terms of exposure. So that world, I think it’s going to grow even bigger for us in, in a rural place like Maine where we are distant from specialists and from referral sites, et cetera. It also opened up some concerns about our education. So many most of our schools went to online education. And did all the kids have the right technology to access that? Did they have the adequate broadband? Some kids had to go to where the local library was to get the assignments. I think it totally again reveals how important broadband is to us. And then finally, if we’re gonna develop really well developed, articulated surveillance systems in public health. We gotta move beyond some of the reporting that still goes on in Maine where data moves by fax machine for heaven’s sakes me, we have got to have much bigger and better data systems. And there is some talk about it in our national contact tracing system and surveillance system. And could Maine even attached to that given some of the black holes in broadband. So i will selfishly say, I hope you voted for the bond issue, shameless promotion, but I’ll tell you my town sure needs it.

Rebecca: Thanks, Lisa. Do you guys have time for one more question? Okay, cool. And we’re so glad so many people joined today. If you need to run, that’s okay. We’ll just stay on for a few more minutes here. So keeping in mind this idea of kind of what are specific policy initiatives or issues we should be keeping an eye on. Not just Covid related but anything that impacts rural health in Maine and nationwide. Do you know what are things that we should be keeping in mind as the Legislature might go back into session, that could help kind of help these issues? Are there things that are slipping through the cracks or things that are not getting resources that they would normally, because resources are being diverted to covid response? What as kind of citizen should we be keeping an eye on as we go forward the next few months?

Deb: So i’ll let me take a first pass at that. And I know there was at least one question about this. First of all, I do believe that there will be some legislative initiatives around rural health infrastructure, public health, as well as clinical care. And whether that is looking to regionalize services. I know there is a nascent effort right now to regionalized perinatal care in the state of Maine. And to formalize relationships among hospitals and tertiary care centers and private sector providers, et cetera. We don’t have a system, so to speak, of perinatal care and the state, whether that becomes a legislative initiative or whether that is done through the private sector, I think is an open question. But regionalizing services and particularly this is important to people who live in rural areas who may not have access to all of the specialty services they need or want because they simply can’t be supported in every part of the state from a financial standpoint and several both Erica and Lisa, mentioned the challenges of recruiting and maintaining health care providers. So regionalizing health care, I think is, is one issue that is likely from a policy perspective to emerge.

Erika: I would say that at the national and even the state level, but it really has to be mostly at the federal level, investing in public health and prevention. We know that only, you know, two out of every $100 or ¢2.5 out of every dollar goes to public health in this country. And so much of it does go to medical care. And rural communities are notoriously under funded. And we know that, that because so many public health communities have to compete with each other for funding, applying for federal grants, et cetera, the most under-resourced tend to be the less successful. And that means that we have a very anemic rural public health system nationally. Which is why we are, as one of the questioners, noted, having to cobble all these resources together at the community level to be meeting these needs.

Lisa: I’ll give it one quick lob, and being that data geek, I would love for the legislature to suggest that we have a really good step back from this, this whole pandemic, when it finally winds down as a bit of a study about how our public health system responded. Are really looking at the data and yes, did most of the cases center on assisted living facilities and nursing homes? And if so, are there some initiatives that we should be instituting for those sectors that help them better? Do we have, has our infectious disease response being crippled over the decades because we haven’t had to have much of an infectious disease response, we’ve moved way more into chronic disease. Maybe we ought to be looking at are structures in Augusta or our lab, our Epid. our infectious disease. And also does it say something about linking up with the infectious disease docs that are out in the various areas that are mostly clustered in Central and Southern Maine, but there are some in Bangor and further afield, should we be developing more of a network? I’d love to see somebody do an analysis of that one when we’re done.

Deb: Lisa, I would just add to that training programs, not only health care provider training programs. Public health was mentioned by Erika, but we, we don’t have all of this is so new that the training programs are not going to catch up if left to their own devices probably for decades. So again, it’s not necessarily a legislative initiative, but there can be some resources potentially that are provided to our state training programs to bring not just health care providers, by teachers and businesses, et cetera, who need to understand both the disease flow as well as the ways that it can be mitigated. Really important.

Rebecca: Great. Erika, Lisa, and Deb, thank you so much for joining me today. This was a great conversation. Really appreciate it. I’m sorry that we could not get to many questions. I could ask are some incredible questions in there, but we’re trying to keep it short today. Feel free to reach out to folks. Reach out to us a few more questions or want to keep engaging in this conversation. This webinar was recorded and it’s going to be available to view and share on our website, www.umainecenter.org. If you’re a podcast, lever will also be converting this conversation into a podcast as well. So you can find it there on Spotify or Apple Podcasts in the next week or so. And then really just we hope you’ll join us for our next Greater Good webinar, which we will announce the topic and date very soon. So just once again, thank you three so much for joining me. Thanks everyone for joining. We had just about little over 80 people on this webinar today, which is great to see. So take care, stay dry out there with these thunderstorms. Thank you so much. Bye.

The information provided in this podcast by the University of Maine System acting through the University of Maine Graduate and Professional Center is for general educational and informational purposes only. The views and opinions expressed in this podcast are those of the authors and speakers and do not represent the official policy or position of the university.