Rural Health Perspectives: West Virginia and Montana Share Priorities

November 17, 2021 | Andrew Tucker

Ayne Amjad, MD, MPH serves as Commissioner for the West Virginia Bureau for Public Health. A native of West Virginia, Amjad has served her home state for many years, from treating addiction to chronic health disease. Maggie Cook-Shimanek, MD, MPH, is the Acting State Medical Officer for the Montana Department of Public Health and Human Services and the Medical Director for the Montana Department of Labor and Industry Employment Relations Division. She is board certified in both General Preventive Medicine and Occupational Medicine.

In recognition of Rural Health Day (Nov. 18), we spoke with Amjad and Cook-Shimanek about the importance of public health in rural areas.

What is Rural Health Day, and why is it important to commemorate?

AMJAD: It is important to commemorate because rural communities and healthcare are critical not only for remote areas but for any underserved area. National Rural Health Day is a way to celebrate these rural or underserved communities and to highlight healthcare providers and recognize challenges that these communities face.

COOK-SHIMANEK: Rural Health Day offers an opportunity to reflect on some of the challenges rural populations face in meeting their healthcare needs, how those needs are currently being addressed, and opportunities for continued improvement in eliminating healthcare disparities.

What are the biggest challenges facing rural health providers?

AMJAD: Rural health providers face many challenges, but a big challenge is providing the best medical care to patients, which can be difficult due to patients’ inability to come to their visits regularly because they may lack transportation or personal funds.

COOK-SHIMANEK: Rural healthcare providers have limited local access to emergency services and specialty providers, including those in the fields of mental and behavioral health and substance abuse.

What is the status of COVID-19 in your state? What unique challenges has the COVID-19 pandemic brought to protecting those who live in rural areas of the state?

AMJAD: Although the state has continued to see a steady downward trend in the number of severe COVID cases, West Virginia has seen the devastating effects of the COVID-19 pandemic and continues to urge all eligible West Virginians to choose to get vaccinated to protect themselves, their loved ones, and their communities. The Mountain State has one of the most vulnerable populations in the U.S. We have an older population with a high rate of comorbidities.

COOK-SHIMANEK: Following a recent surge, Montana has fortunately seen a recent decline is COVID-19 case rates and hospitalizations. A priority for the state-led COVID-related efforts has been ensuring rural access to testing, vaccination, and therapeutics. The pandemic has highlighted some of the practical implications of access issues that rural populations face. The capacity for rural and frontier counties to provide care directly, or transport to, a higher level of medical care has been present throughout the pandemic and factored into surge and crisis care planning. Vaccine storage conditions influenced the timing vaccination for those unable to travel to larger cities. Equitably distributing COVID-19 therapeutics across a geographically vast state has proved challenging, particularly for those products administered intravenously. Some of these challenges were novel in nature (e.g., access to ultracold storage for vaccine), but our state has faced comparable challenges with rural healthcare access in the past, with the prior experience proving useful in this pandemic response.

What changes have you made over the past 18 months to address those challenges? (E.g., telehealth)

AMJAD: Increasing broadband services does improve services in rural areas, also allowing providers to use basic telephone services for care if needed because some patients are not familiar with web-based services.

COOK-SHIMANEK: The CMS 1135 waiver provided an opportunity to test some of the rules previously imposed on telehealth delivery. The 2021 Montana legislative session produced House Bill 43, which revised existing laws related to telehealth—including expansion of the definition to include audio-only communication. Some rural populations do not have access to high-speed internet, making audio-only visits an especially important option. Similarly, removal of an existing requirement for an in-person encounter prior to initiating telehealth could create access for those who would otherwise have to travel to a larger city for healthcare.

Are you looking at a transition, or “off-ramp,” from COVID-19? How does that look in a rural setting?

AMJAD: It is difficult to predict the future because the situation is still fluid, especially with the possibility of other variants in the future. However, vaccination continues to be a major priority and we continue to urge all eligible West Virginians to choose to receive the COVID-19 vaccine as soon as they can. West Virginia’s driving principles will continue to be building community immunity by protecting our most vulnerable, reducing deaths, reducing hospitalizations, and maintaining critical services and acute care.

Health officials are predicting an increase in flu activity this year. What are you seeing in your state so far?

AMJAD: The percent of outpatient visits due to influenza-like illness statewide was 0.6% for the week ending October 23, 2021, which is below our statewide baseline for influenza activity. The number of influenza tests reported for this week was 2,956, which was above the pre-pandemic average of 2,300 per week.

COOK-SHIMANEK: There have been four lab-confirmed cases of influenza so far this year. The state continues to promote co-administration of the flu and COVID-19 vaccines as a means to avert additional stress on the healthcare system through respiratory-related hospitalizations.

Overall, the public health workforce is overworked and, in many cases, the target of harassment and threats. How are public health staff doing after 18 months in the pandemic? What steps are you taking to support staff, and to recruit for the future?

AMJAD: We encourage staff to be open with any threats received. Offering mental health support is critical, along with moral and social support at work.

Public health has seen an increase in funding, in some cases to historic levels. What has that additional funding allowed you to do, and what more needs to be done?

AMJAD: Funding has helped with increased COVID-19 testing and other COVID-related items, which has shed a brighter light on the need to address health care inequality needs, affecting racial and minority groups and rural areas of our country. It has also shown the need to improve mental health for patients’ medical care and our own medical/personnel staff. We need to continue down this path and not forget these other areas of health care that need help. And we should not need a pandemic to remind us of these things.

Is there anything else you’d like to share?

AMJAD: Rural health care areas, to me, means any underserved area of medical care. It doesn’t have to be in a remote part of a state. It can be in a city as well. It is a group of people not being served adequately.