Rural communities have unique vulnerabilities worsened by the pandemic [PODCAST]

 

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“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.

He shares his story and discusses the KevinMD article that he co-wrote, “A Southern California outbreak highlights failures of the American health care system.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Eric Rafla-Yuan. He’s a psychiatrist, and he co-wrote the KevinMD article “A Southern California outbreak highlights failures of the American health care system.” Eric, welcome to the show.

Eric Rafla-Yuan: Thank you, Kevin, for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Eric Rafla-Yuan: Sure. So I am a psychiatrist in San Diego. Like you said, I’m a recent graduate from the UCSD psychiatry residency program, but one of the great opportunities I had there throughout my training was to get invested in the community settings, so really looking at the public health sector and how our communities are served by the health care system. And then specifically, what I’ve really been passionate about is looking at our immigrant and refugee communities and what we can do to help support them.

Kevin Pho: Excellent. And how is the pandemic affecting you and your practice?

Eric Rafla-Yuan: My practice is just getting started, but because of the pandemic, everything is now 100 percent online, which, fortunately, telepsychiatry is one of the easier specialties to do that with.

Kevin Pho: And is there anything that you’ve learned over the past few months doing telepsychiatry that you could share with the other clinicians who may be listening to this podcast who also may be seeing patients virtually?

Eric Rafla-Yuan: So I had the fortune of seeing patients through telepsychiatry before COVID-19, and so it wasn’t as big of a transition for me. I think some of the biggest lessons that I’ve learned are more about how to navigate some of the logistics rather than the actual clinical encounter. So once you get into the flow of it, it’s more or less mostly the same, at least for psychiatry. Obviously, some physical exam things are different. But navigating how you’re going to contact them: What do you do if there are issues with a connection? Do you have a phone number to contact them? What if there’s some escalation needed, you need to get to the hospital? How do you arrange all of that? You’re not there in your office.

Kevin Pho: So let’s get into the KevinMD article that you co-wrote, “A Southern California outbreak highlights failures of the American health care system.” Now, for those who haven’t read your article, can you share the story behind it and walk my audience through it?

Eric Rafla-Yuan: Sure. So here in San Diego County, we’re bordered to the west by the Pacific Ocean, to the south by Mexico, and to the east by Imperial County. And then Imperial County shares that border with Mexico and with us, and to the east of them is Arizona. So it really is a desert, and it’s one of the more rural communities in California. There are less than 15 psychiatrists in the entire county. They don’t have a single psychiatric hospital.

One of the things that we saw in Southern California was that cases of COVID-19 were sharply increasing in Imperial County. Initially, some public health experts had thought that some of the more rural counties might be more spared, because it’s easier to social distance and population density isn’t as high. But really, what we saw in Imperial County was an alignment of previously existing public health vulnerabilities that led it to a situation where COVID-19 was really rising more quickly there than anywhere else in the state.

Kevin Pho: Now let’s get into more detail. What were some of those specific vulnerabilities that existed before the pandemic?

Eric Rafla-Yuan: Sure. And so the highlight of the article was really to look at these specific things and show that this doesn’t really have anything specifically to do with COVID-19, but these all pre-existed and are all inherent to the American health care system.

So one of them is that the health care infrastructure, which includes mental health infrastructure, is much less developed in rural communities. Rural communities have less access to medical care of all kinds, including specialists, and in this case, COVID-19 testing and treatment.

Another thing that we saw is that rural communities are more likely to be disenfranchised in a number of ways socioeconomically. Imperial County as well has a large number of immigrant families and community members, and these communities have been targeted by the current federal administration in a number of ways, including ways that would disincentivize them or penalize them for seeking out COVID-19 testing or treatment.

Kevin Pho: Telemedicine has been advocated as one way to increase access. Now, are you seeing that as a potential solution to the immediate problem?

Eric Rafla-Yuan: So telemedicine has been utilized by Imperial County and other rural areas, especially in California, for quite some time now. In fact, UCSD, where I work, collaborates with telemedicine support in multiple specialties with the main medical center in Imperial County. So that has been pre-existing COVID-19.

Telemedicine is also being advanced now specifically for COVID-19 support. So, for example, UCSD has been involved in telemedicine endeavors with hospitals in Mexico, where their ICU staff or volume just isn’t, where they don’t have the infrastructure that we have in San Diego, to help them develop the COVID-19 protocols and such. But in terms of the actual ICU patients and bed numbers, telemedicine obviously isn’t able to do much with that, which is one of the big issues in Imperial County.

Kevin Pho: What are some of the policy solutions that can address these issues? And knowing that policy sometimes takes a little bit of time to implement, what are also some immediate solutions that we can implement to help with these problems?

Eric Rafla-Yuan: Yeah. So you’re definitely right that policy tends to be complicated and takes some time, because there are so many factors to consider. Part of the issue in health care policy is that it’s tied to so much, and so it’s hard to make a substantial change without changing a larger system, but that larger system is really consistent.

But looking at the individual vulnerabilities, some of the more simple ones would be policies that didn’t penalize community members for seeking out care or treatment, especially in the case of COVID-19. For example, the Trump administration’s push for a public charge policy, which would penalize people for utilizing public benefits, really disincentivizes people to seek out testing and treatment, which they’re congressionally entitled to. So that could be a simple change, and it would be a simple executive order from the president or the attorney general.

In terms of looking at how health care infrastructure is developed in rural counties, that would be something that would need effort at all levels: the state, the federal, and the county level. But I think that something that this CDC director has talked about is that public health infrastructure is not where we need it to be. That’s been under-invested in this country for many years.

Kevin Pho: We’re talking to Eric Rafla-Yuan. He’s a psychiatrist, and he co-wrote the KevinMD article “A Southern California outbreak highlights failures of the American health care system.” One of the things that you mentioned in your article was divorcing health care from employment. Can you tell us how that can potentially help?

Eric Rafla-Yuan: The United States is the only country in the world that has this, a large, a majority, proportion of the population where health care is dependent on an employer. And that grew out of more or less what is a quirk in World War II, where salary increases were frozen, and instead employers offered various other benefits, one of them being health insurance. And then this kind of snowballed into what we have today.

But as we are now seeing, when people lose their jobs, then they lose their health care. And this is an issue when there’s a pandemic and many people are losing their jobs. The last thing we want is for people to not have health insurance and not have the ability to get testing or treatment for COVID-19. Most other countries don’t have this issue, because their health insurance provision does not come through employment but rather comes through the public sector or by private companies. And so, again, this is something that would need a coordinated effort from the federal and state administrations.

Kevin Pho: So in the upcoming election, if we end up with a Biden administration, he’s proposing to strengthen what we currently have with the Affordable Care Act. In your view, will that be enough to address some of these issues going forward?

Eric Rafla-Yuan: Yeah. So there are obviously a lot of details to be worked out in terms of what the president is proposing, or the presidential candidates are proposing, and what will actually be enacted into policy. But I think that anything that we can do that would increase health care access to citizens of this country and residents of this country would improve our ability to increase access to testing and treatment for COVID-19, which would end the pandemic sooner in this country. And I think that’s what everyone wants.

Kevin Pho: And my final question, Eric: Do you have a take-home message that you want to share with the KevinMD audience?

Eric Rafla-Yuan: With COVID-19 striking the United States pretty badly, and striking some communities worse than others, it’s not necessarily because those communities are genetically more predisposed, or something about those communities, sort of from a medical or biological basis, makes COVID-19 more severe there. But really, from a public health perspective, these are all communities that we could have mapped out and known that they were going to get hit harder. And so if this is the case, if we already know this information, and we know that there are things we can do to work with this information, then that’s something that we need to invest resources in. Because if there are communities in our country where COVID-19 is continuing to ravage through the community, it affects all of us.

Kevin Pho: Fantastic. Eric, thank you so much for sharing your time and insight. Thanks again for being on the show.

Eric Rafla-Yuan: Thank you for having me.

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