As CNN and other outlets report, rates of COVID-19 have been overwhelming Imperial County, California, for the past two months. Bordered to the west by San Diego County, to the east by Arizona, and to the south by Mexico, the rate of new infections and deaths are higher here than anywhere else in California. Local hospitals have been flooded, and a federal field hospital continues to be at capacity. To many, this seems an anomaly—the Imperial Valley is a sparsely populated area known for its rich agricultural heritage. However, as the region struggles to slow the tide of new cases, the virus continues to expose flaws inherent in our current health care system, which, like many small tributaries, have joined in a torrential outbreak.

Rural communities and geographic disparities

The limited health care infrastructure in rural areas is ill-equipped to handle the deluge of need during a pandemic. Rural communities lag in almost every health-related metric. There are fewer doctors and other health care professionals; fewer hospitals, and less access to specialists. Travel for care poses additional barriers, especially when many rural areas have limited public transportation routes. Federal and state funding for county health and human services agencies—often proportioned based on population—leaves many rural counties struggling to develop needed infrastructure. Mental health services in rural communities share a similar fate. Imperial County has no inpatient psychiatric facility, and patients in need may wait days in an emergency room before being transferred to a facility in an adjacent county for treatment.

Socioeconomic inequities

The social and economic determinants of health are widely known. The CDC concludes that “conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes” and that “differences in health are striking in communities with poorer conditions.” According to California state records, one in four people in El Centro, the largest city in Imperial County, live below the poverty line, and unemployment rates here are far above the national average, a trend that continues during the pandemic. Poorer areas are associated with higher levels of air pollution, a major risk factor for the development of lung diseases, including COVID-19, and El Centro ranks in the top 10 of the nation’s most polluted cities.

Health care tied to employment

A uniquely American quirk is the linkage of health care coverage to employment, a remnant of World War II policy. The widespread loss of employment during COVID-19 has led to millions of individuals losing health care benefits during the pandemic. Actions of the Trump Administration threaten millions more, as it continues its attempts to weaken or eliminate health care benefits guaranteed through the Affordable Care Act. Poorer, rural areas that may depend more on public health benefits will be especially devastated if the federal administration is successful—approximately half of the population of Imperial County is enrolled in the Medi-Cal program.

Outdated and fragmented technology and policies

Investments in health care and public health infrastructure have not kept pace with those of other sectors. Outdated federal compliance policies mandate the use of fax machines and other obsolete and inefficient methods for communication of essential data. Laws meant to shepherd patient privacy inadvertently require huge amounts of time to keep up with bloated administrative paperwork. A complicated maze of in-network, out-of-network, and other adjacent but unconnected systems cause both health information, as well as patients themselves, to fall through the cracks, perhaps never making it to the next step. Rural communities are especially disadvantaged, as they have even fewer resources to shift to more modern technology.

Historically disenfranchised minority communities

The Black Lives Matter movement is bringing increased focus to the structural contributors of health disparities for racial and ethnic minorities, such as felt in Imperial County, a majority Latino community. While some strides have been made in representation in reporting, The California Department of Public Health reports that Latinos make up 39 percent of California’s population but 55 percent of confirmed COVID-19 cases. Border communities have also suffered under recent Trump Administration immigration directives. One such policy, Public Charge, penalizes legal immigrants who are pursuing a permanent residency in the U.S. for utilizing public benefits, such as health insurance. As an article published in the Journal of the American Medical Association points out, policies such as these deter community members from accessing needed health care, including vaccinations, worsening the health of the entire community.

While Imperial County faces a confluence of vulnerabilities that have led to its susceptibility during COVID-19, it is not alone. Like an insidious undercurrent, these deficiencies are lurking in every region of the United States. Structural issues require structural solutions—to effectively contain COVID-19, our local, state, and federal leaders must address these underlying faults in the foundation of the systems which we rely on to maintain our personal and public health. As COVID-19 continues to aptly demonstrate, when the health of part of our community is imperiled, we are all imperiled.

Eric Rafla-Yuan is a psychiatrist. Janet Ma is a cardiology fellow.

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