INDIANOLA, Miss. — Chad and Kelsey Dowell, both doctors in this small, impoverished town in the Mississippi Delta, have cried a lot in recent weeks. The reason is the same every time: the coronavirus.
Sometimes, they find themselves weeping when a patient carrying an oxygen tank is finally able to leave the South Sunflower County Hospital, where they work. Sometimes, they tear up on their back porch when they think of the few options left for another COVID-19 case. Sometimes, the couple, both 32, are overcome at the dinner table while their two young kids argue in the next room over what movie they want to watch.
Andrea Morales / for NBC News
Their emotions are stretched thin by the flood of patients they see struggling to breathe, their own inability to respond to the pandemic with the limited resources at their rural hospital, the immense nursing and staffing shortages they face, the resistance members of their community feel to keeping themselves safe during the outbreak and the rising number of deaths from the disease that seem to come as a result.
Indianola, best known as the hometown of B.B. King, and the state as a whole shut down from the beginning of April until the end of May, when Gov. Tate Reeves announced that all businesses could reopen. Since then, masks, social distancing and other acts of vigilance disappeared, while resistance to taking the disease seriously has only continued to grow.
“To everybody in town that I see posting on Facebook about how this isn't real and that it’s a political scheme, I'm like, ‘Oh, my God, come intubate these patients,’” Kelsey Dowell said from the back porch of her home. “‘Come see what we see. It's real.’”
Andrea Morales / for NBC News
Mississippi and Sunflower County, where Indianola is located, have seen the virus grow precipitously in recent weeks since Reeves gave his reopening order — a decision he made even though the number of cases across the state continued to trend upward.
The spread in this area is particularly scary because of how vulnerable the people who live here are. This county sits within the Mississippi Delta, a region that is predominantly Black. Longstanding health and social inequities have led to coronavirus hospitalization rates among black people to rise five times higher in the United States than for white people, the Centers for Disease Control and Prevention reported last month.
And while the Delta served as the center of numerous struggles during the Civil Rights Era, the work that started then isn’t nearly complete. Organizers say that the Mississippi Delta, among the most socioeconomically disadvantaged areas in the country, is often an afterthought for state leaders.
"Mississippi hasn't put resources in our hospitals to take care of folks in the Delta, and I'll tell you why: It's because they ain't white," said Arekia Bennett, the director of Mississippi Votes, a progressive organization that aims to engage state voters, especially its disenfranchised Black population. "We have to do better as a state when it comes to public health, and we need to start now."
On Tuesday, Mississippi hit single-day highs in the number of cases, patients in intensive care units and patients on ventilators, according to the Mississippi State Department of Health. The state also saw 18 more coronavirus deaths on Wednesday, bringing its total to 1,290. More than half of the people who have died are Black.
Reeves has since reversed course, mandating masks Monday for the 13 counties with the highest rates of infection, including Sunflower County.
Despite the governor’s insistence that Mississippians now need to wear masks and take social distancing seriously, his new stance appears to have come very late. Hospitals across the state, including the one where the Dowells work, had already said they were overwhelmed. Five of the state’s largest hospitals reported last week that they had run out of ICU beds and four others reported having fewer than 5 percent of their ICU beds available.
Aggravating the situation further is the fact that Mississippi is one of the states with the fewest health care resources in the country and it doesn’t have enough medical workers to contend with the huge influx of patients, which includes coronavirus cases and people who put off their elective procedures during the shutdown.
Medical institutions in Mississippi have long seen a staffing shortfall, especially with nurses, even prior to the pandemic. But now, with medical workers testing positive for the disease and a growing turnover rate, these hospitals are beginning to have to limit the number of beds they can responsibly oversee — even if they have the space for more patients.
Only about 40 percent of Mississippi’s more than 51,000 registered nurses report working in hospitals and just 15 percent are trained in critical, trauma or emergency care, according to the Mississippi Board of Nursing. Registered nurses in Mississippi are also some of the lowest paid in the country, making approximately $14,000 less than the national median of $73,300, according to the Bureau of Labor Statistics.
Turnover at the state’s hospitals and long-term care facilities was already a problem before the pandemic, and it has only continued to grow in Mississippi since the virus has spread, said Kim Hoover, a registered nurse who now works as the chief operating officer of the hospital association.
“To be honest with you, some have just said, ‘if I'm going to work and possibly be exposed to COVID-19, maybe take things home to my family or friends, then I'm going to go where I can make the most money,’” Hoover, the former dean of the University of Mississippi Medical Center’s School of Nursing, said.
She said she has a meeting with the hospitals’ chief nurse executives to discuss staffing challenges. They’re looking at ways of using medical and nursing students to shore up their gaps and avoid costly staffing agencies, which can provide registered nurses to fill gaps but at a premium price that many medical institutions in this state cannot afford.
‘They are tired … they’re scared’
South Sunflower County Hospital is well aware of the staffing shortfall the state faces. At night, it sometimes only has one nurse for up to 11 patients because so many nurses have called out sick or are unable to work because of the coronavirus.
Hoover said the ratio should be closer to 1 nurse for every 2 ICU patients or 1 nurse for every 3 to 5 patients who need a normal amount of care.
There was limited backfill at the hospital in Indianola even prior to the pandemic, and now nursing supervisor Ricky Pate is often left to do everything he can to ensure that patients are comfortable, from fetching protein shakes to watching their breathing — all while sweating profusely under numerous layers of personal protective equipment.
“Trying to get people to come to work outside of their normal rotation is hard,” he said. “Money will not even hardly motivate them to come in because they are tired, and there’s quite a bit of anxiety and stress that comes with this. They’re scared, and they want to spend as much time as they can with their family.”
The patient load has buried medical workers across the Mississippi Delta.
Dr. Satwinder Singh, the only epidemiologist in the region — an area slightly smaller than the state of New Jersey — said he’s never seen so many patients coming into the Delta Regional Medical Center where he works, a hospital in Greenville, about 23 miles west of Indianola.
Singh said he began pushing local leaders to respond to the pandemic after seeing warning signs of the disease in March.
“It was frustrating because I have no authority to control things,” he said. “I can tell someone that something is coming and we’re going to need help, like Dr. [Anthony] Fauci is, but I can’t force anyone to respond.”
Now the area is overwhelmed with cases, and while the hospital where Singh works is larger than the one in Indianola, it recently had to cut its number of ICU beds in half — from 16 to eight — because so many of the nurses had been infected.
Singh also noted that the Delta and Mississippi as a whole have limited testing capacity. With a low number of tests being sent out and a backlog at labs creating untenable delays for results, Singh said that there is no understanding of how far the infection has reached — even among his colleagues.
“There are nurses who we have now that we don’t know if they’re positive or not,” he said. “There are a lot of asymptomatic people, and we don’t have enough tests to test everybody. So because they cannot be tested, you don't know who has the disease. But it's way more, maybe 10 times more, than what we are counting now.”
The limited beds and staffing in other parts of the state add to the bad news for patients here who are in need of treatment and already face limited health care resources in one of the poorest regions in the country.
‘Many others will perish’
Kelsey Dowell, who is currently taking a tour leading the hospital’s coronavirus response here in Indianola for two weeks, recently spent more than three hours calling 13 different hospitals hoping to find a medical institution that could take one of her COVID-19 patients who was in critical condition. One person who answered her call at another Mississippi hospital laughed when she asked for a bed.
“The patient was on 10 liters of oxygen, and then she burst her bowels,” Kelsey Dowell said. “So she needs an ICU bed, surgery and she’s COVID positive, like, everybody's laughing at that when I tried to ship her.”
Her husband, Chad, was in a similar boat a few weeks ago when he was in charge of responding to the hospital’s coronavirus cases.
He reflected on one patient who began struggling to breathe. Aware of his hospital’s lack of resources, Chad said he knew full well that he needed to move the man to another facility. So he began to call medical centers across the state.
“There I am: Can’t get the guy in any hospital,” he said. “And If that guy stays here, he’s gonna get a tube, but I can’t wash his lungs out — I can’t do any of that s---. If he stays here, he’s gonna die.”
He was finally able to get the patient moved to a larger hospital in Tupelo, more than 150 miles to the northeast. A family member of the patient told him a few days later that the person had got control of his breathing and was getting better.
The next morning, Chad woke up to a text that the man had died.
“He just had this black-green gunk all over his vocal cords, and of course I know it’s all in his lungs and that’s why we couldn’t get him to oxygenate,” he said. “It just killed me because we got him there. He was getting better over four or five days, reading on his own even, and then I wake up to that message.”
Both Dowells said their hospital is not equipped to deal with the standard of care many patients require, adding that it’s particularly scary in a region of the state facing massive health inequities and outcomes. The Mississippi Delta has the highest rates of heart disease, diabetes, hypertension, obesity and stroke in the country — all conditions that can make someone particularly vulnerable to COVID-19 — according to the Centers for Disease Control and Prevention.
The two doctors said they are tired, morale is low at the hospital and some have had to take pay cuts because of the low number of patients. Seeing people in their community not wear masks or practice social distancing amid the outbreak only makes things worse.
Some locals have even mentioned herd immunity to the Dowells, dangled casually as a solution on the horizon — a concept particularly popular among those who aim to dismiss the size and the scope of the disease’s outbreak. Experts say relying on herd immunity could lead to millions of deaths.
It’s a point of view that even the Mississippi governor has pushed back against. Reeves, a former banker, used his finance and mathematics background to explain why Mississippians shouldn’t depend on herd immunity in a series of tweets that went viral, warning that the state would need to increase its worst single-day number of infections threefold every 24 hours for a year to get anywhere close to herd immunity.
That ignores the fact that the state’s hospital system is already overwhelmed, he said.
Unless you’re willing to go without hospitals after a car wreck or heart attack, we need a different approach. Right now, despite mixed messages at the beginning, it seems like masks are the best bet. They’re a hell of a lot better than widespread shut downs. Please wear one!
— Tate Reeves (@tatereeves) July 13, 2020
But Singh does not have much faith that the Mississippi Delta, the state or the country will be able to pivot in time to stop the spread of the infection, especially as the response to the virus has become politicized within the region's white community.
The epidemiologist said that because of the resistance here to masks, social distancing and staying home, many will undoubtedly die and hospitals will be overrun.
“That’s why we may end up with herd immunity” he said. “Only the strong — or the people who take it seriously — will survive and many, many others will perish. I hate to say it, but we’re almost at natural selection at this point.”