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A nurse from Lee County who was working in a Tennessee hospital discovered she was pregnant in March 2020. Then the COVID-19 pandemic hit. And for four days on the job, she didn’t have an N95 mask — because the hospital said there weren’t any to give her.
“It was like going to the DMV to try to get an N95,” she said in a recent interview. “They said, ‘We don’t have enough masks to spare.’ So I worked four shifts without one.”
She said treating a ward full of COVID-19 patients was especially scary as research surfaced connecting the disease to blood clots.
“And I actually have a history of clots while pregnant,” she said. “So I’m trying to protect my patients. But I’m trying to protect myself as well.”
The nurse’s story of on-the-ground struggle is just one of many featured in the new book “Masks, Misinformation, and Making Do: Appalachian Healthcare Workers and the COVID Pandemic.” Wendy Welch, who proposed and edited the January 2023 nonfiction release, said her goal was to talk to the people “frontlining the pandemic” — and capture what they were seeing every day on the job.
“I didn’t see those stories in the media,” Welch said. “I think there were a lot of people who didn’t understand what a quagmire, what a Catch-22, what a perfect storm downward spiral the pandemic was for health care.”
Welch had access to health care workers through her role as director of the nonprofit Graduate Medical Education Consortium. The nurses she talked to “blew like volcanoes,” Welch said. Until she asked, Welch said they felt they had no one else to talk to.
“Because in many cases, it’s a requirement of safety for the health system to not have anyone talk about the health system,” she said.
That’s why providing an anonymous space to share real experiences was key, Welch said. The nurse from Lee County used a pseudonym for the book exactly for this reason: to protect confidentiality and her own employment.
The nurse worked in eastern Tennessee until December 2020, then went on to work in Roanoke and in Morgantown, North Carolina. In every location, she said, some patients feared and distrusted health care workers, often insulting nurses and resisting help.
“I saw so many deaths that I felt could have been prevented had they watched different media,” she said. “We normally take care of our patients, but during a period when nobody could visit the hospital, we were the patients’ everything. And for them to still doubt our intentions all the time, it was really hard.”
As the only Black nurse in the room working at a time of confrontational conversations about race and the Black Lives Matter movement, she faced discriminatory remarks and treatment from fellow health care workers and patients.
“There were a lot of microaggressions,” she remembers. “Some of it was from a place of just not knowing, but it was still scary. Because at the time this was going on, there were Black patients. And I’m just thinking, what do you think of this patient when you walk into the room? What do you see?”
‘You can’t get a vaccine from a clinic that doesn’t exist’
The book is divided into three sections: background, stories and impact. The background section, spearheaded by Beth O’Connor, director of Virginia Rural Health Association, chronicles the economic frailty experienced by rural hospitals pre-pandemic. According to O’Connor, rural health services “have been undermined since World War II.”
“People looked at the rates of the pandemic in rural versus urban and pointed at rural communities and went, ‘Oh, those people are too stupid or too ignorant, they don’t understand science,’ without having the whole background that we don’t have access to services,” O’Connor said. “You can’t get a vaccine from a clinic that doesn’t exist.”
The lack of long-term health care providers and services contributed to widespread misinformation in rural Appalachia, O’Connor said.
“The majority of information people are receiving about COVID is through social media,” she said. “But when people don’t have a trusted family doctor to turn to, what else is there?”
Lynn Elliot trains medical students to become rural physicians in family and internal medicine through the Graduate Medical Education Consortium. She said the “unique” Appalachian culture contributed to resistance to care.
“People in the hospital would paint these rocks, and write things like ‘God is in control,’” Elliot said. “So there was sort of fatalism that is typical of Appalachia — fatalism combined with this very fierce independence of ‘I’m not going to be pushed around, no one is going tell me what to do.’”
The pandemic, and news coverage of it, did not hit rural areas until later on, Elliot said. Rural residents would watch the news break in New York while there hadn’t been a single case in their communities.
“So it was like watching it happen to other people,” Elliot said. “We had a president who said it was a hoax. So it’s like, what kind of game is being played to tell us that this pandemic is going to strike us when we don’t see it? That seemed ridiculous, or far-fetched, to people who weren’t experiencing it.”
Racial trauma breeds mistrust
Black patients in Appalachia were especially skeptical about the pandemic — and for good reason, the Lee County nurse said. Some conspiracy theories targeted the Black experience directly by catering to racial trauma from the 20th century Tuskegee experiments, which left syphilis untreated in Black men to study the infection’s effects.
“Whenever we hear things like vaccines and different treatment options, of course our minds go back to the Tuskegee experiments, which were once thought to be a conspiracy but were very real,” she said. “So there was a distrust of, are they really gonna take care of me? Or is this vaccine not really about protecting me, and they’re trying to poison me?”
Black patients also worried about inclusion in clinical trials for treatments, and general quality of care, she said. She understands these fears all too well, after experiencing that patient-side racism firsthand during a miscarriage in 2020.
“I’ll never forget them asking me questions that I did not feel like they would ask a white female,” she said. “Was the pregnancy planned? Is the father in the picture? How many other kids do you have?”
She said her doctors didn’t even ask if she had prior miscarriages. “I’ve seen many microaggressions. I’ve seen language changes. And I do feel those experiences very well.”
Because of this, she felt the “urgent need” to protect all Black patients that came through her hospital doors.
“You’re just wondering, if this patient had lighter skin and the same person taking care of them, would the care be different? Would there be more concern about the pain they’re in? Would they be more listened to?” she said.
‘We’re not running out of body bags anymore’
The nurse remembers being treated like a hero by some and a villain by others.
When she walked into the room of a Black patient, “they were relieved,” she said. But some patients, after receiving care from white nurses, would see her and “all of a sudden, they want security to secure their purse,” she said.
Sometimes, she said, opinions would change. While working in North Carolina in late 2021, she discovered a heart condition in one of her patients. She started treating it intentionally — and slowly, the patient became more open about his symptoms.
“He went from barely wanting to talk to me and his wife addressing me for the first day, to holding my hand by the fourth,” she said.
The patient later died from a heart attack. But when his wife saw the nurse in the hallway, she hugged her.
“I still think of him,” the nurse said. “I still remember her name.”
She is still working as a nurse in North Carolina, at a hospital where she is no longer the only Black health care worker on staff.
“Now, there are fewer COVID patients and we have better treatments,” she said. “And I’ve only had one death in months. So we’re not running out of body bags anymore.”
She spends less time convincing patients that COVID-19 is real, too. But there are still days she feels burned out.
“I’ve never wanted to think of my job as, ‘Let’s get through these 12 hours,’” she said. “But often, I do.”
‘Both a lesson and a metaphor’
Welch said both the overarching trends, like O’Connor described, and the personal narratives, like the nurse’s, are essential to truly understanding the pandemic’s impact in rural Appalachia.
“There was that big story of the economic trouble,” Welch said. “But then there were also the little stories of the nurses who were literally having things thrown at them. And in the last five minutes of their life, these patients who realize they had not made good choices for themselves and they’re going to die, they reach for their hands. And these women are there for them.”
These nurses aren’t just heroes, Welch said. They are “friends of humanity” — a phrase she borrowed from an herbology class to put in the book’s preface.
“One of the herbalists said, people are always looking for medicines that will cure things, but some of these plants, they’re not heroes, they’re everyday companions, they’re friends of humanity,” Welch said.
When the pandemic started, Welch saw the overworked nurses and thought of that quote.
“These are not people who are geared up to run a race. These are people who upped their levels at the job they do every day anyway,” Welch said. “These are friends of humanity, because they’re there all the time. And they’re going to be there, no matter how tired they are.”
Through these stories, O’Connor said she hopes readers realize their own connection to rural health care and check their biases.
“The issues in rural were not caused by rural,” she said. “This is a system-wide problem.”
And the problem will persist, Welch said. That’s why unity is an important takeaway.
“There’s going to be another crisis; it’s not going to be the same thing,” Welch said. “Let this be both a lesson in specifics and a metaphor for the next one. We are in this together. And if we don’t share and play nice, well, we’re going to kill ourselves along with trying to kill the other person.”