In 2017, when the U.S. Department of Homeland Security declared the electoral system “critical infrastructure,” state and local election officials around the country were forced to take cybersecurity much more seriously. And it wasn’t long before physical threats and misinformation also became a greater concern. 

In North Carolina, state board of elections director Karen Brinson Bell said the DHS’s designation “didn’t take anything off her plate.” Instead, the responsibilities of election officials like her only grew, especially in battleground states like North Carolina.

In the lead up to this year’s election, Brinson Bell said “everything is a concern” when it comes to election security. Like her counterparts across the region, she’s especially focused on cybersecurity, preventing physical threats and battling misinformation around the elections process, while communicating to voters that the electoral system in North Carolina is actually safe and secure. 

“We had to become much more adept at telling our story, being accessible to the public, helping them understand what is really a complex, methodical, multilayer process in all that we do,” Brinson Bell said. “And it’s not soundbite friendly.”

Other states in the region like Pennsylvania, which was at the center of the 2020 election denial campaign and is considered a “must-win” for both former President Donald Trump and Vice President Kamala Harris in this year’s presidential race, are also confronting the same concerns as North Carolina. 

Earlier this year, Pennsylvania launched a task force focused on election threats like misinformation related to the adoption of new voting systems and no-excuse mail-in voting.  

“In recent years, we’ve seen bad-faith actors attempt to exploit these changes by spreading lies and baseless conspiracy theories, and attempting to delegitimize our safe, secure and accurate elections,” said Pennsylvania Secretary of the Commonwealth Al Schmidt in a February news release. “This task force has been working together to develop and coordinate plans to combat this dangerous misinformation and continue providing all eligible voters with accurate, trusted election information.”

2020 Hindsight

Many election officials didn’t have a plan for handling the 2020 presidential election fallout, Brinson Bell said. From protests fueled by misinformation and lawsuits seeking to overturn the results, states like Georgia and Pennsylvania were mired in controversy, and North Carolina was “just on the bubble” of facing the same issues. 

“For North Carolina, we have to think about, what can we learn from those states?” Brinson Bell said. “It’s unfortunate what they went through, but it’s unfortunate if we don’t learn from it.” 

In North Carolina, according to one recent poll, nearly 50% of those who responded said they won’t believe the results of the election.  

One major focus for Brinson Bell is making sure that voters understand the election process and how it actually operates — even promoting physical transparency at the county level, like urging election staff to use clear plastic tubs with labels to store ballots instead of recycled cardboard boxes. 

“That’s not election jargon,” Brinson Bell said, “but it’s something clear to the public.” 

Now, Georgia, another battleground state in the region, is mired in controversy surrounding its state election board, which recently approved new rules that critics believe will “sow confusion, compromise ballot security and potentially enable rogue county boards to block certification of election results in November,” according to reporting by the Washington Post.  

Later this month, the board is scheduled to vote on whether to require counties to count ballots by hand at each precinct, which critics believe could produce inaccurate results and be less secure. 

Georgia Secretary of State Brad Raffensperger described the election board as “a mess,” and told the Washington Post, “Legal precedent is pretty clear. You shouldn’t change rules in the middle of an election.” 

Physical Security, New Rules and Turnover

Elections officials are also working to boost physical security in the lead-up to the election. 

In North Carolina, Brinson Bell said workers are securing doors and installing panic buttons at county elections offices. Staff are also being trained in de-escalation techniques to counter voter intimidation and other physical threats. Earlier this year, Georgia passed an election security law requiring police to take a one-hour class on election laws, which also included training in de-escalation, though the new law doesn’t go into effect until 2025. 

In North Carolina, a 2023 voter identification law will be in effect for this year’s election and photo ID will be required. Mississippi, Georgia, Tennessee and Ohio also have strict photo ID requirements for voting.

Staff turnover, specifically county election directors, has been another concern of Brinson Bell, who earlier this summer said more than 60% of county election directors have left their post since 2019. For many of the replacements, she said, this will be their first presidential election. 

“While there’s much that’s the same processes and routines, the volume, the intense scrutiny and being a battleground state with so many high profile contests on our ballot this year, it’s just a different environment to be a new director,” Brinson Bell said.  

Urban-Rural Divide

It’s not just Appalachia’s battleground states taking election security seriously. Other states in the region are also working to combat misinformation and thwart physical and cybersecurity threats.

Deak Kersey, chief deputy and chief of staff for the West Virginia Secretary of State’s Office, said the state has focused on cybersecurity since DHS’s critical infrastructure designation went into effect. 

“West Virginia was not in a great spot eight years ago,” Kersey said. “Nobody knew what cybersecurity really was, as far as the Feds really considered it.” 

Since then, the state has pushed to disperse Help America Vote Act, or HAVA, funds to counties, which have used the funds to update voting equipment, like purchasing new ballot-marking equipment that’s ADA accessible and electronic poll books. In August, the state election commission approved sending nearly $1 million in HAVA funds to 24 counties. 

DHS also awarded $1 million to North Carolina this year, but the money can’t be spent until the state’s General Assembly authorizes it. If and when it does, then the state elections office will have to decide whether to disperse it between counties or keep some of it at the state level to continue funding a statewide cybersecurity expert to monitor for doxing, denial-of-service attacks, phishing schemes and other online threats.  

“I don’t mean to make light of a million dollars, but that doesn’t go far in a state with 100 counties,” Brinson Bell said.

The funding issues hit especially hard in the state’s rural counties.

“I think some of the concerns in Western North Carolina really are reflective of sort of that rural-urban divide in North Carolina — the economically distressed counties versus those that are prospering more,” Brinson Bell said. 

It’s a concern across Appalachia, where most of the region is rural. And while federal funding will help, elections officials have less than two months left before the election to see how far it will go to update equipment, implement new security measures and hire new people to replace outgoing directors.

The post In Appalachia’s Battleground States, Election Officials Worry About Cyber Security, Physical Threats and Misinformation appeared first on 100 Days in Appalachia.

By Grace Vitaglione

Child care took center stage at the legislature this past year, as advocates sounded the alarm about potential closures and/or price hikes when federal funding dried up in July. But the issue of affordable and accessible child care has been around for far longer. Public funding for child care in North Carolina stagnated for a decade before the pandemic. 

That’s part of why the sector’s in crisis now, advocates say. 

“This has been a problem that’s been smoldering for over a decade, and the pandemic threw gas on it, and now we have a crisis,” said Sherry Melton, lobbyist and consultant for the NC Licensed Child Care Association.

In June, state lawmakers agreed at the last minute to direct about $67 million to keep child care providers afloat for about six months. House Speaker Tim Moore (R-Kings Mountain) said at the time that the rest of the funding would come through in January.

“When it comes to child care, this is a key thing that we need to fund because we know we need a workforce,” Moore told reporters in June. “There are mostly women that are affected by this, but some men as well who cannot enter the workforce because they cannot afford or do not have access to child care.”

But this week, though lawmakers have been back in Raleigh to do a budget update, child care has not been on the table.

Most states, including North Carolina, primarily support child care with federal funds and supplement it with state money, Melton said. But neither federal nor state dollars have kept up with higher costs. In recent years, funding increases from North Carolina’s lawmakers have been “incremental and gradual and not enough,” she argued.

But some states do a better job than North Carolina in accommodating the growing cost and need for child care, mostly by dedicating funding to keep child care centers afloat and changing reimbursement rates and criteria.

Variable funding over time

Public money for child care in North Carolina usually flows into specific programs. This ensures that child care providers have multiple avenues for support, according to Ariel Ford, who just stepped down as the director of the Division of Child Development and Early Education at the N.C. Department of Health and Human Services. 

There hasn’t been a large state investment in early childhood education since the early 2000s, Ford said. And while federal money has increased, she said it’s not increased nearly enough.

In the 2011-12 biennium, when Republicans took over the state legislature, leadership said that one of their main priorities was to cut spending, as reported by multiple outlets at the time. The state legislature overrode a veto by then-Gov. Bev Perdue and made around a 20 percent budget cut to Smart Start and NC Pre-K (then called More at Four), EducationWeek reported. 

That was the beginning of flat funding in the state for child care, Ford said. 

For example, Smart Start saw a cut of more than $30 million in the budget appropriations from 2010-11 to 2011-12, according to the organization’s 2012-13 annual report.

Having multiple sources of child care subsidy, and differing eligibility criteria, can be complicated. Smart Start Chief Strategy Officer Safiyah Jackson said it can be difficult for parents to figure out where and how to access help, but that Smart Start can serve as a “lighthouse” to direct them to resources in their community.

Mostly flat budgets

Smart Start is a comprehensive approach to early childhood from birth to age 5, Jackson said. It’s primarily funded by allocations from the state legislature, with some private dollars added on — usually about a 15 percent match. The program is not just child care support, it also includes things like child and family health programs. Most of their funding does go to early childhood education. 

What also is confusing is that the term “Smart Start” refers to the network as a whole, which is made up of the NC Partnership for Children — a statewide agency — along with 75 local, county-based partnerships with independent nonprofits that help children.

The statewide organization distributes funds among the county-based partnerships, as well as provides support and oversees the local partnerships, Jackson explained. Legislation requires Smart Start to spend 70 percent of its budget on early child care and education, with the rest going to functions such as family support, child and family health programs or local systems building.

The local organizations are public-private partnerships that raise money of their own in addition to the state money they receive. The state budget instructs them how much they have to raise in matching dollars and sets limits on what they can spend on administration. 

About half of the overall Smart Start network’s budget goes to subsidies to help families pay for child care; each local partnership distributes those dollars within the community, Jackson said. That’s separate from the state child care subsidy program, which goes through the DHHS Division of Child Development and Early Education.

From the years between 2011 and 2023, the state budget allotment for child care subsidy programs stayed roughly around $110 million, according to data from the legislature’s nonpartisan Fiscal Research Division provided to NC Health News by lawmakers. In the past fiscal year, that number ticked up by about $30 million.  

State funding for child care capacity building, including Smart Start-related activities, has hovered around $52 million since 2011-12, according to the Fiscal Research Division data. Those dollars include tuition reimbursement for early education teachers, as well as assistance for child care facilities to increase or maintain their star rating level. There’s other Smart Start funding that goes to child and family health programs, family support and other forms of local child care support.

During the dark days of the pandemic, funding for child care was a rare bright spot. Typically, federal support for child care to North Carolina runs at about $400 million a year, but that grew to about $1.3 billion a year as a result of the American Rescue Plan Act, Ford said. 

Those funds allowed the centers to bump up teacher pay, hire more teachers and even provide people with benefits, sometimes for the first time.

More recently, state lawmakers prioritized more funding for child care. In fiscal year 2024-25, lawmakers increased the state budget for the child care subsidy program to $150.5 million, according to the Fiscal Research Division.

State lawmakers also directed almost $1 million in funding to the NC Tri-Share Child Care Pilot Program in 2023, in which employers, eligible employees and the state equally split the price of child care for working families. That’s becoming an avenue for some families to apply for a child care subsidy, but the pilot is only available in select counties.

Facing a cliff

But those extra federal dollars for child care came to an end this past summer, prompting something of a crisis for many child care centers. 

The end of those dollars prompted a flurry of advocacy activity this past summer, where providers, parents and business leaders all pushed lawmakers for money to maintain child care funding. 

State lawmakers responded with an additional $67.5 million to make up for some disappearing federal pandemic-era dollars. According to advocates, it wasn’t nearly enough. 

Lauren Horsch, spokesperson for Senate Leader Phil Berger (R-Rockingham), wrote in an email that the state “would not be in this situation had Congress not pumped tens of billions of dollars into states and then pulled the rug out from under them.”

“Addressing the childcare needs in North Carolina is going to take more than just money, and simply having the government subsidize childcare is not a long-term solution,” she said. “Conversations about the role of the business community and any potential policy solutions will undoubtedly take place as legislators prepare for next year’s long session.”

Some states started increasing their investments into child care, such as increasing subsidy reimbursement rates and giving child care teachers better access to care for their own children.

The population of children aged 0-4 in N.C. increased from over 543,000 to about 596,000 from 2000 to 2023, according to data from Carolina Demography. While the number grew overall, there was a big rise in the number of preschoolers in the 2000s which slowly drifted down. 

The needs of young children with mental, emotional and behavioral challenges have increased along with the cost of care, Iheoma Iruka, professor in the Department of Maternal Child Health at UNC Chapel Hill, wrote in an email. She also pointed out that young children are often undercounted in the census.

“Just doing a flat line investment is not going to keep things open, given the cost of everything that we have here, particularly for child care providers and the workforce costs,” she said.

The recent drop in the number of children doesn’t justify flat funding when services — especially property and labor in N.C. — have increased in cost so much, Melton echoed.

The post Child care shortage isn’t a new problem; advocates decry decades of inadequate public money appeared first on North Carolina Health News.

With chronic high unemployment, industry losses and a declining population, Edgecombe leaders hope Natron battery plant will spark renewal.

Can battery plant jump-start Edgecombe County’s sputtering economy? is a story from Carolina Public Press, an award-winning independent newsroom. Our breakthrough journalism shines a light on the critical overlooked and under-reported issues facing North Carolina’s 10.4 million residents. Please consider making a contribution to support our journalism.

By Jaymie Baxley

People in rural communities depend on local pharmacies for more than just prescription medicines.

Many rural pharmacies offer immunizations, blood pressure testing and other services that can be difficult to get in remote places where traditional health care providers are few and far between. In some areas, a rural pharmacist “may be the only trained health professional in town,” according to Professor Delesha Carpenter of the Eshelman School of Pharmacy at UNC Chapel Hill.

“If you wake up with a rash or some kind of bite, the pharmacist is the most accessible health professional,” she said. “You don’t need an appointment, you don’t need health insurance and they’re often open after providers’ offices have closed.”

But rural pharmacies across the country are struggling. A recent study by the Rural Policy Research Institute (RUPRI) at the University of Iowa found that the number of retail pharmacies in rural communities across the U.S. declined by 5.9 percent from 2018 to 2023.

North Carolina is not immune to the trend. In an email to NC Health News, Fred Ullrich, program director for RUPRI, said at least three rural municipalities in the state — Faison, Selma and Tryon — lost access to retail pharmacy services during that period.

Carpenter said pharmacy closures can be devastating for rural communities, where residents skew older and are more likely to live with obesity, high blood pressure and other conditions than their urban counterparts. They also face greater transportation challenges and higher rates of poverty.

“When a rural pharmacy closes, people lose access to that health care provider and there may not be anything else in town,” she said. “There might not be anywhere else for them to go, especially if they’re uninsured — and there’s high levels of people being uninsured in rural communities. Where can those folks now go?”

Competing with cities

Joe Moose, who with his brother runs Moose Pharmacy, a 142-year-old business with eight locations in the Central Piedmont, fears the state will lose more rural pharmacies in the future.

He said the ever-rising cost of prescription drugs has created a “volume market” that favors corporate drug stores in urban areas. Smaller, independently owned shops in more sparsely populated communities, meanwhile, “make very little or nothing at all” from filling prescriptions.

“You can’t even keep the doors open if you don’t have volume, and density generally creates volume,” Moose said. “That becomes really challenging when you’re trying to pull from 10,000 patients over a 30-mile, rural setting versus 10,000 patients over a half a mile setting.”

While rural pharmacies get a higher reimbursement rate for some prescription drugs, Moose said the difference is negligible and not enough to sustain a pharmacist’s salary.

“Pharmacists are expensive,” he said. “You’ve got to get a certain amount of volume just to cover that expense before you get into all the other stuff like the electricity and water bills, the rent and the insurance.”

Another challenge, Moose said, is attracting qualified pharmacists to rural communities, which may be seen as less desirable places to live.

“If a person’s invested a ton of money in their education to become a pharmacist, do they want to go back to a rural area? Or do they want to be in a city like Charlotte, Raleigh or Greensboro?” he asked.

Reimbursement woes 

Moose believes many of the financial issues plaguing rural pharmacies can be traced back to pharmacy benefit managers.

These companies set the reimbursement rates for prescription drugs. They also decide which drugs are covered by health insurance plans and where those drugs can be dispensed —  often with little government regulation.

States have been reluctant to regulate pharmacy benefit managers, but some states have started. This year, 12 state legislatures made moves to rein in pharmacy benefits managers, according to a report in Politico, with more anticipated after this fall’s election.

“If you want to pinpoint one thing that has led to closures, it’s that the hands of pharmacies are tied on the amount of money that they can charge,” Moose said. “Somebody tells them how much they can charge and how much they’re going to get reimbursed, and that number keeps ratcheting down every year. It’s consistently declining.”

“Legislatively, we need to make their activities more transparent so people can see the cost of things and see where their dollars are going,” he said.

Moose isn’t the only rural pharmacist who wants to rein in pharmacy benefits managers. Carpenter, who directs a rural pharmacy research network that includes more than 150 pharmacies, said the network’s members identified the companies as a top financial threat in a recent survey.

“Pharmacies get reimbursed less than what they pay for these prescriptions,” she said of the rates set by the pharmacy benefit managers. “On some brand name medications like Ozempic, a pharmacy can lose up to $100 per prescription to dispense it.”

And many contracts with the pharmacy benefit managers require local pharmacies to dispense a medication, even if it’s a money-losing proposition.

“They’re having to take a financial loss on the medication,” Carpenter said.

If that hemorrhaging of money cannot be stemmed, Carpenter and Moose say, more rural pharmacies are likely to fold.

Some of these at-risk establishments may convert to alternate dispensing sites, which is what RUPRI said happened to the pharmacy at Crescent Foods in Faison. These facilities are more specialized and limited in their operations, according to RUPRI.

Others, like Creech Drug in Selma and Owen’s Pharmacy in Tryon, could simply shutter.

“In rural communities, it’s particularly negatively impactful when a pharmacy closes because people know their rural pharmacists,” Carpenter said. “It’s not like an urban CVS where somebody walks in, gets their prescription and leaves without even exchanging names.

“These are folks that have significant relationships with their customers that are coming in. They know their customers’ families. They know their names.”

The post Prescription for crisis: Rural pharmacies struggle to stay open appeared first on North Carolina Health News.

By Rose Hoban

In April, North Carolina’s agricultural officials received an unwelcome surprise. Cows in one of the state’s dairy herds tested positive for a strain of avian influenza that’s been appearing in herds throughout the United States since the spring. 

State veterinarian Mike Martin relayed the story of how North Carolina discovered the information during a recent gathering of 150 farmers, county and state agricultural officials, and federal regulators at a panel discussion convened by N.C. Agricultural Commissioner Steve Troxler.

Martin said his office knew cows from the Texas panhandle where the outbreak was first identified had been transported to North Carolina and that routine testing for the virus, not identified symptoms, had led to the identification.

“We had already started to work on establishing a relationship with that farmer, talking with them, making sure they’re doing things in a biosecure fashion, and trying to educate them on the information that we knew as we got it,” Martin told the group gathered at the state fairgrounds in Raleigh.

Martin also told the crowd that the genetic sequence of the virus found in North Carolina-based cows was the same as the genetic fingerprint of the avian influenza virus in the Texas herd. Veterinary officials believe the Texas outbreak was the result of the cows’ contact with wild birds migrating through the center of the country in late 2023 or early 2024.

Martin said the North Carolina case was the first time cattle without symptoms of the disease had been detected in the U.S. outbreak, which now spans 14 states and 197 confirmed cases. In the past month, the disease was detected in Colorado, California, Michigan and Idaho.

Thus far, North Carolina has had just the one confirmed case. 

That’s the way Troxler wants it. And his goal is for North Carolina to have no more cases going forward, despite the large number of cows that get moved around the country. That means frequent testing and providing compensation to farmers who are affected.

“It’s a numbers game. The more virus that’s out there, the more likely it is to be mutated and spread to other species,” Troxler said. 

And while there’s risk to cows — and people — chickens and turkeys could be devastated if the virus got into poultry flocks. Troxler reminded the audience that agriculture, with its $111 billion in annual economic impact, is the state’s largest industry.

“And we are particularly vulnerable because of the size of our poultry industry in North Carolina,” he said. “We actually ranked No. 1 in the nation in egg and poultry receipts.”

Bird flu in cows? 

Highly pathogenic avian influenza, H5N1, has been spreading around the world for decades, closely watched by both veterinary and human health officials because of its potential to cause a devastating human pandemic. In the past several years, the disease — which has caused outbreaks in countless commercial poultry flocks throughout the U.S. and the rest of the world — has jumped from birds to other species. 

The disease has killed mammals on almost every continent in the past few years: red foxes in the Netherlands in 2021, thousands of sea lions and tens of thousands coastal birds in Peru in 2022, and a massive die-off of elephant seal pups in Antarctica and the Atlantic coast of Argentina in 2023. A polar bear died in Alaska last winter. Sea lions on the Pacific coast in Peru and the Atlantic coast in Uruguay have died from the disease, and the list goes on.

When “high path” avian influenza outbreak hits a farm — a thought that strikes fear in the hearts of commercial poultry farmers — Troxler said the fatal consequences can be swift. “Maybe overnight, half of the chickens are already dead,” he said.

That’s when agricultural officials jump in quickly, typically euthanizing an entire chicken house to keep the disease from spreading further.

What’s different about this outbreak in cows is that the disease, which usually affects the respiratory tract (think coughing chickens) is affecting different parts of the animals. In cattle, the virus seems to show an affinity for the cows’ mammary glands, where milk is produced. Symptoms for the cattle include reduced appetite and feeding, and reduced milk production. The milk that is produced comes out thick and yellow. 

Cows tend to recover in a few weeks. But it’s not benign for all animals that come in contact. The Centers for Disease Control and Prevention issued a report of barn cats dying after drinking unpasteurized milk on a farm where the disease had been identified in cows. 

Eric Deeble, a cattle veterinarian and undersecretary for marketing and regulatory programs at the U.S. Department of Agriculture, was on the panel that Troxler convened last week. He said his agency is compensating farmers for their losses while their animals are sick. 

The indemnity programs were quickly implemented by the federal agriculture agency to help farmers who can’t sell milk on the market while their cows are sick. Dumping the product could be devastating for their bottom lines. 

“It’s important, that message, that a farmer — if they detect this in a herd, will not lose their market,” Deeble said. “If there is somebody who suspects that they may have this on their farm, it’s really in their interest to come forward, because there are indemnity programs that can offset the losses that they will experience as this moves through the herd.”

Those incentives are there, in part, as an incentive to keep farmers from hiding cases, he added. 

Managing the spread

If farmers hide cases, and health and veterinary officials don’t know about it, then the virus is sure to keep moving, agricultural officials say — in part because it’s not clear how the virus gets from cow to cow. 

“We’re looking at things like mats, flooring, insects, milking equipment, individual hands, the equipment people are using for pre- and post-milking dips, dip cups, those sorts of things, towels,” Deeble said. “We know that it’s not an aerosolized infection, for which we’re very grateful.”

Several dozen cattle workers throughout the country have contracted the disease, which has largely shown up as cases of pink eye.

The more cases that get into humans, the bigger the risk that the virus could mutate to become transmissible from person to person as a respiratory disease. That’s what health officials have been watching for in Southeast Asia, where, for instance, several children were infected with a respiratory disease after handling dead chickens last year. In Vietnam and Cambodia, several people have died, but, thus far, the disease has not shown the ability to be passed from person to person, only from animal to person.

In the spring, Martin, the state veterinarian, heard from his peers in Idaho that there had been an outbreak in a herd that had received dairy cattle from the Texas herd with the initial outbreak — the same herd that had sold cows to the North Carolina farmer.

“The Texas cows probably brought it over, cleared the virus, and now it was just our native cows that had the virus,” he said. 

“The farmer, much to his credit, gave us the ability to test this herd and work forward under a time when it wasn’t even recommended to test this herd, and we developed a testing protocol,” Martin added. “We basically tested all the positive cows that came from that herd until they stopped testing positive.” 

But, as Troxler noted, it’s a numbers game. The more cases there are in other species, the more chances there are for the notoriously mutable avian influenza virus to mix and match DNA and start spreading. 

One easy way to contain potential spread to humans is by pasteurizing milk, all of the panelists said.

Headlines this spring proclaimed that evidence of high path avian influenza had been found in parts of the nation’s milk supply, but Troxler was quick to explain that what was found was evidence of the virus’ DNA, not the virus itself. 

He noted that pasteurization — where milk is heated to high temperatures for a few seconds and then rapidly cooled — completely kills the virus, leaving behind only scraps of its DNA that pose no danger. 

“Pasteurization takes care of all of it. I know that the first time that we started doing the testing for pasteurization, ‘Does it really kill it or not?’ the public had to know for sure that it killed it,” Troxler said. “There’s no mistake. Pasteurization does take care of this pathogen in the milk and other pathogens.” 

The post State agricultural, veterinary officials stay on the lookout for bird flu in NC cattle appeared first on North Carolina Health News.

Lilian Melgar Martínez started her day at 5 a.m. to harvest tobacco and sweet potatoes in the fields of Duplin County in North Carolina. As temperatures sweltered and the work days stretched into night, sometimes she would faint. 

La entrada Undocumented and Undiagnosed: The Fight to Ease A Health Crisis Among North Carolina’s Farmworkers se publicó primero en Enlace Latino NC.

The average cost of storm repairs is about $10,000 for “moderate” wind-based damage, and a minimum of $4,000 to handle water damage. That’s less than a quarter of a new home price. Add in price-gouged flood insurance costs and consider a scenario of heavy damage, rebuilding is still a fraction of buying anew.

Read more via Scalawag: Weathering Storms.

Bridging Access:

Across rural America, communities of color may be facing barriers to health care, but they’re also laying the groundwork for a more equitable future. Whether it’s hospitals reopening, a community’s holistic approach to maternal care, or the grassroots work to bring comprehensive  services to immigrants, these stories offer a road map. This story is part of a collaborative reporting effort led by the Institute for Nonprofit News’ Rural News Network, with visual support from CatchLight.  Photo credits: Ariel Cobbert and Aallyah Wright.

BROWNSVILLE, Tenn. — On a late evening in 1986, sharp pains hit Alma Jean Thomas-Carney’s stomach like lightning.

Days earlier, she’d just returned home to Brownsville, after dancing all weekend at her high school reunion hundreds of miles away in Illinois. Maybe that’s where the pain originated, she thought.

She cried profusely to her husband to take her to a hospital. But not the local Haywood Park Community Hospital, a 62-bed facility built in 1974.

“Please don’t take me up there. Don’t take me up there,” she pleaded. He rushed her to the car and drove to Jackson, Tennessee, nearly 40 miles away.

When she arrived at the hospital in Jackson, she underwent exploratory surgery. They found cysts on her ovaries, a diagnosis she says she wouldn’t have gotten at Haywood Park.

“I didn’t trust I would get the proper care or care that would help me to survive,” she told Capital B.

Years prior, she experienced an unwelcoming environment from white staffers, including doctors, at Haywood Park. Upon entry, she’d walk to the reception desk, only to be ignored or met with unpleasant looks. 

“They acted like you were invisible,” she said. “Whether they were talking or drinking coffee, they kept doing whatever they were doing and didn’t pay attention to you.”

Haywood Park’s reputation deteriorated over the years. Some residents voluntarily drove elsewhere if they could, or went without critical care, which contributed to low patient volume. Many more reasons, such as financial instability, resulted in its ultimate demise.

The hospital closed in 2014, after a long, slow decline. But, the news saddened the community, including Thomas-Carney. “Despite my ill-feelings or experiences I had in that environment … you have indigent people living in Haywood County who need to get to the closest facility available.”

From 1990 to 2020, 334 rural hospitals have closed across 47 states, which disproportionately affect areas with higher populations of Black and Hispanic people. Since 2011, hospital closures have outnumbered new hospital openings. In Brownsville, they’ve been able to do the impossible: reopen a full-service hospital. They’re not the only ones. 

Less than three hours away in the heart of the Mississippi Delta, leaders in Marks reopened their facility in 2021, after a five-year shutdown. In neighboring Georgia, county officials received millions in congressional funding to reopen their hospital in Cuthbert, which closed in 2020. Currently, they’re researching what model is feasible for their town. 

When a rural hospital closes, there’s usually no turning back. Yet, Brownsville became an outlier two years ago and is part of a growing but short list of hospitals in rural counties that have been able to fully reopen. What’s happening in this 68% Black town of 9,700 people is quite uncommon, health experts say. Usually hospitals cut back or reduce services, such as obstetric departments, to keep their doors open. The most recent alternative to prevent closures include the Rural Emergency Hospital designation, a new model established in 2020 that eliminates in-patient beds but keeps an emergency department in order to receive a boost in federal support. At least 29 rural hospitals have converted to rural emergency hospitals, according to Becker’s Hospital Review.

While this is a fix for some, it may not be the most viable for others, experts say. 

“Once you’ve seen one rural community, you’ve seen one rural community; they’re very different. We understand that not every rural hospital that is struggling will benefit or will want to convert to this rural emergency hospital,” said Shannon Wu, senior associate director of payment policy at the American Hospital Association. “We see this as a tool in a toolbox for those that fit their community needs.”

Why the distrust runs deep 

Thomas-Carney lost faith in the local health system long before the establishment of Haywood Park 50 years ago.

As a kid, she witnessed her grandmother lying in a hospital bed in the basement of the Haywood County Memorial Hospital, a 30-bed facility built in 1930 during Jim Crow. Steel pipes followed the linings of the walls. The sounds of steam echoed in her ears.

“I just remember looking around, and it didn’t look like nothin’ that I had seen in a book about a hospital,” she explained. 

Thomas-Carney’s grandmother’s experience was not uncommon, as most Southern, white-run hospitals refused to accept Black patients. The few that did placed them “on inferior Black wards, often in the basement, and usually with no separation by disease process,” writes historian Karen Kruse Thomas. 

Kruse Thomas details how prior to World War II, hospitals in the South were racially separate and Black patients mostly went to all-Black hospitals, if they had one. Few and far between, Black hospitals were unaccredited, underequipped, and struggling to remain open. 

In the 1940s, the federal government began to address hospital segregation through the Hospital Survey and Construction Act, known as the Hill-Burton Act. At the time, the South had the highest population of Black folks with the worst rates of morbidity and mortality. In 1938, the surgeon general called the South “the number one health problem in the nation.”

Today, the health disparities can be described the same. 

Black people still experience higher rates of disease, chronic illnesses, and mortality in comparison to their urban counterparts. In Tennessee, Haywood County has higher percentages of adult diabetes, obesity, and overall poor health in comparison to the state and national averages. 

Unfortunately, where you live dictates your health and the type of access you have.

Only recently did a study in the National Library of Medicine distinctly spell out that structural racism — in addition to poverty, education, and environmental conditions — is a major contributor to why such health disparities continue to persist.  

“In rural areas, especially in the South, it is important to understand how institutional policies, such as the Jim Crow laws that segregated hospitals and neighborhoods, led to differences in resource allocation between white populations and nonwhite populations, which may impact healthcare access today,” the study’s authors noted. 

Greta Sanders, a Brownsville resident, recalled how Eva Rawls, a Black registered nurse who worked at Haywood County hospital, was forced to work under the supervision of white women who were licensed practical nurses, even though she was the superior.

That hospital closed in 1974, the same year Haywood Park opened.  

“When [the new owners] found out that a registered nurse was working underneath the LPNs, they were just blown away,” said Sanders, a retired lab technician who worked at Haywood Park. “When the white LPNs had to start working under her supervision …  they did not like it.” 

Advocacy for critical and preventive care isn’t enough

Many residents in Brownsville — the birthplace of the Queen of Rock ‘n’ Roll, Tina Turner — have received life-saving care at the local hospital. 

One of those people: the wife of John Ashworth, a local civil rights activist and historian who co-runs the Dunbar Carver Museum with Thomas-Carney. Some time ago, Ashworth’s wife got stung by a bee. By the time she arrived at Haywood Park, her blood pressure was extremely high. They immediately admitted her and stabilized her.

“I have mixed emotions, but I really think it was a good hospital,” Ashworth said. “I am absolutely convinced that my wife would not be alive today if that hospital had not been there at the time.”

Ashworth believes some deaths could have been prevented had the hospital been open. 

Fed up with the poor health outcomes in his community, William “Bill” Rawls Jr. ran for office. He became the first Black mayor in Brownsville in 2014. Before he could celebrate the win, the hospital closed its doors for good. 

So, he thought.

Rawls set out on a mission to work with Michael Banks, a local attorney, and county officials to bring back the hospital. Like many small towns, the train tracks here still represent a divide, a symbol of racial segregation.

While Banks worked to find quality suitors for the hospital, Rawls started the Healthy Moves Initiative, a health education and preventive care effort. He hosted health fairs, quarterly free wellness screenings, built walking trails and a dog park, and created a farmer’s market. But, it didn’t create the impact he’d hoped for. 

It’s still a work in progress, he says, but the challenge is getting more participation.

Two years after Brownsville lost its hospital, Marks, a small town in the Mississippi Delta, did, too. The closure of the only critical access hospital in Quitman County resulted in the loss of 100 jobs. Similar to Brownsville, limited health care access resulted in longer waits to receive emergency and medical assistance.

Six months later, the Black town of 1,600 people lost its only grocery store.

During this time, Velma Benson-Wilson returned to her hometown after 20 years in Jackson, Tennessee. It started as frequent trips to conduct research to write What’s In The Water?, a tribute to her mother. She stayed a bit longer to work as a consultant on cultural tourism for the county, particularly the construction of the Amtrak project and memorializing the history of the Mule Train, which kicked off the late Martin Luther King Jr.’s Poor People’s Campaign.

But, the health crisis and food desert in Marks motivated her to dig deeper. 

Wilson became the Quitman county administrator, the first Black person and female to serve in the position. After she helped close the Amtrak deal in 2018, she turned her focus to the hospital and worked with the county supervisors to find a solution.

After working to save a hospital in Holly Springs, roughly 90 minutes from Marks, Quinten Whitwell, an attorney from Oxford, and Dr. Kenneth Williams, a Black physician, launched Progressive Health Group to keep rural hospitals from closure across the South. 

Five years after the Marks hospital closed in 2016, its Certificate of Need was set to expire. The legal document was required to reopen, establish or construct a health facility.

Whitwell, in quarantine, worked with his team on a plan to get it approved by the state.

Manuel Killebrew, president of the Quitman County Board of Supervisors, said that state Democratic Sen. Robert Jackson passed legislation to help reopen the hospital. Soon after, in 2021, the county supervisors voted to reopen the hospital in partnership with nearby Panola Medical Center in Batesville, Mississippi. The county gave Whitwell’s group a loan, and Citizen Banks of Marks gave a $1 million donation to reopen the facility as Progressive Health of Marks, a critical access hospital. The same year, a local entrepreneur opened a new grocery store across the street from the hospital.

The hospital has a walk-in clinic, emergency room, radiology department, and several other services, such as telehealth, according to Mejilda Spearman, the administrator for the Quitman hospital. They currently have four in-patient beds and are currently renovating their senior care unit. They’ve hired fewer than 50 people. While they’ve seen a steady increase in patients since, they still struggle to get community support. 

But, some residents still aren’t satisfied, Killebrew added.

“There’s still people who gripe, but the hospital here is the closest place to get medical treatment,” he said. “If one of their loved ones were shot or had a heart attack, they get here, and at least they’ll survive.”

A Georgia community gets a second chance

Despite low support in Marks and Brownsville for a hospital, residents in Cuthbert, Georgia, have prayed for more health care options in their predominantly Black community of fewer than 3,100 people.

The Southwest Georgia Regional Hospital in Cuthbert, the county’s only hospital, closed at the height of the COVID-19 pandemic due to increased costs from aging infrastructure and underinsured and uninsured patients. Officials added that the inaction of Medicaid expansion in Georgia also contributed to the closure in Randolph County, which is majority Black. 

Before the hospital closed, some uninsured residents relied on the emergency room for primary care. Now for emergencies or other care, many travel 30 minutes to Eufaula, Alabama, or nearly an hour to Albany, Georgia, said Cuthbert Mayor Bobby Jenkins. 

Minnie Lewis, a retired educator, travels to Albany and Columbus frequently for appointments and would love to eliminate the additional time it takes for roundtrips there.

“In fact, I just had a health scare, but I had to go to have a CT scan there. Then I had to go to Sylvester [Georgia] to a hospital there because they didn’t have enough space there for me for that particular thing,” she said. “I would have had that CT scan right here in Cuthbert, if it was open.”

When the hospital closed, the doctors left, too. Until about a year ago, the town had no doctors, despite Care Connect, an urgent care clinic, opening immediately after the hospital closed in 2020. Jenkins and residents hope the draw of a hospital will bring more jobs, affordable housing, and food options into the town, which is racially divided.

“With the white there and the Black here, you can’t get nothin’ done. We don’t go to church together, but at least we can have some common ground when it comes to the community and for the betterment of all the citizens,” said Cuthbert council member Sandra Willis. 

The hospital is the only issue that they’re united on, she says. The majority Black county commissioners, all-Black city council, and Randolph County Housing Authority have worked together to figure out a solution.

They’ve been able to get the attention of their state and federal officials. After four years, they have a plan.

Earlier this year, U.S. Rep. Sanford Bishop and Sens. John Ossoff and Raphael Warnock requested congressional earmarks to develop and reopen Southwest Regional. They secured more $4 million from the USDA Community Facilities Program and more than $2 million from HUD for the Randolph County Hospital Authority to move forward, according to a spokesperson in Bishop’s office.

There’s no date for when a hospital, or some version of it, will be reopened in Cuthbert. Will critical access, rural emergency hospital, or freestanding emergency department work best? County officials contracted with a third-party to conduct a feasibility study to decide what route to go with the hospital.

“What we hope is to have an emergency room so we can get ‘em stabilized,” State Rep. Gerald Greene said in a phone call. “We’re hoping this is going to work, but we’ll have some [inpatient] rooms. That’s our plan.” 

‘True systemic change is a grassroots effort’

In Brownsville, it took six years to find a solution. In attorney Banks’ eyes, it was all “pure luck.”

On a recent tour of the hospital, Banks — who is now CEO of Haywood County Community Hospital — pointed out a bed that displayed colorful LED lights with symbols, advanced technology that checks oxygen levels, weight, and heart rates.

“If a [patient] gets too close to the edge, the alarm goes off. So, the nurse at night – rather than waking someone up – they can come out and look at those lights.”

He credits Braden Health, the hospital management group that took over the hospital. As counsel for Haywood County, Banks would take prospective buyers on “a tour with a flashlight” because the building was boarded up. None of the deals panned out — until 2020 when they met Dr. Beau Braden, an emergency medicine specialist and co-founder of Braden Health. The county officials agreed that Braden Health could take if they improved the property and ran the facility as a full service hospital. 

Two years later, they reopened Haywood Park Community Hospital, under a new name: Haywood County Community Hospital. They downsized to nine in-patient rooms and have a staff of 80 employees, all from Brownsville or neighboring communities.

In addition to an emergency room, they have an urgent care walk-in clinic, pharmacy, mammography, ultrasound, and radiology department. Despite the new infrastructure and quality, Banks averages about five patients a day, and about 25 patients in the ER. But, there have been times when they’ve had to send patients to other facilities because they are full, he said.

Residents stop by often for the handprint ceramic tile wall in the main entrance of the hospital. In the 1990s and early 2000s, kids in Brownsville painted these tiles. Many people come back to find their handprint. They built a conference room so local organizations can meet. They also eat at Annie Mae’s Cafe, a soul food restaurant in the hospital named after Tina Turner and run by two local cooks who lost their restaurant during the pandemic. 

Banks, the mayor and residents, are optimistic about the hospital’s future. In fact, they’re planning to expand, adding things like a physical therapy section. They expect more traffic, especially with the opening of Ford’s Blue Oval mega facility.

“Ever since we opened the inpatient side, we’re breaking even. We’re profitable and growing more every month,” Banks said. “Even if Brownsville stayed the size it was, we’d be fine.”

Staying on top of the accounting, rural health-related policies and regulations, and making sure insurance providers pay is the key to being sustainable, Banks says. 

Beyond federal dollars, there’s a need to expand Medicaid, increase Medicare payments, and incentivize health care professionals to work in rural areas, rural health experts say. They also advocate for health equity, specifically on better pay systems for rural hospitals and ensuring those investments focus on communities that have “faced historical and contemporary challenges of racism.”

Ultimately, everyone has to work together — government officials, local agencies and the residents.

“People are dying. Not because the hospital is there or not there. It’s because we’ve not taken control. We’re accepting a lesser quality of life and a shorter life expectancy,” Rawls said. “True systemic change is a grassroots effort, but you will need people from the top pushing legislation that’s going to allow rural hospitals to survive or reopen.”

The post Healing a Dark Past: The Long Road to Reopening Hospitals in the Rural South appeared first on Capital B News.