Imagine practicing in a rural area. Things are going along relatively smoothly, with the joys of day-to-day practice outweighing the challenges. Then suddenly, your area is cut in two, and a good chunk of your population can’t access health care or even life-sustaining supplies. What do you do? What do your patients do?
In many areas, you might be able to circumvent the problem, albeit less conveniently, by finding another road. But if you’re on an island, that’s not always possible, something I know only too well from my experience with Hurricane Irma. For about a week after the storm, the Florida Keys, where I practice, was cut off from the rest of the world until travel to the area was deemed safe.
Another clinician who has come to appreciate the special challenges of natural disaster on an island is fellow pediatrician Dr. Janet Berreman. Dr. Berreman’s knowledge comes from many years of experience in island health care: first as a pediatrician on American Samoa, then on Oahu. More recently, she’s been fulfilling the role of District Health Officer for the island of Kauai.
In other words, Dr. Berreman is well qualified to speak to what happens when you practice in an area surrounded by water. I sought her out partly to see if she shares my feelings about how we are different in both good and, well, “challenging” ways. Certainly, unless you’re practicing on, say, Staten Island, island care is largely rural care. (For us, there are times when things might not seem very rural. Kauai, with an island population of 72,000, has 25,000 tourists at any one time. And the Florida Keys, despite a population of about 75,000, can have over 2 million visitors in a given year. Yet based on our local, year-round population, we are both considered to be in rural counties.)
We share many health care delivery experiences with other practitioners in sparsely populated areas within the U.S. We lack access to specialists and tertiary care inpatient facilities. There can be high clinician turnover. Getting needed equipment and, sometimes, even routine medications in a timely manner can be problematic. But why does practicing on an island seem even more different?
Right off the bat, Dr. Berreman and I find common ground in an answer that comes to mind almost immediately: the populations we serve. It’s not an issue of ethnicity, nor of the economic status of our clients. Rather, it has to do with the finite space in which we live. Small towns everywhere have a certain close-knit atmosphere, and everyone tends to know everyone’s business. However, there’s a feeling of insulation that seems to be greater on an island which affects how people interact with each other. Dr. Berreman notes: “People connections are greater on an island than in other rural areas.” The family you’re treating you might see at their small business, where you’re a client; in a church or social group; and out grocery shopping or dining.
While this closeness has its rewards, sometimes there is a downside. Dr. Berreman mentions a colleague that regularly runs into patients outside the office, leading to a dilemma of whether to greet them and acknowledge a relationship. She also notes that the relative lack of anonymity can, at times, make people reluctant to seek care for such issues as reproductive health. “HIPAA is a big challenge,” she notes, echoing my own experience; on an island, it can be more of a theoretical concept than something that is straightforward to put into practice.
No doubt, such social considerations can affect health by limiting access to care. But what of other public health issues? In light of the recent spate of measles cases, I’ve wondered: are there special epidemiologic challenges that result from island dwelling? Fortunately, the Florida Keys have had no reported measles cases since 1998, but is the potential there?
Dr. Berreman notes a mumps epidemic on Kauai during the 2017-2018 season. She also notes that according to a study recently published in The Lancet Infectious Diseases, Honolulu—though not a rural area, certainly an island community—is the tenth most likely county in the U.S. to incur a measles outbreak. Apart from their island status, the Florida Keys and the Hawaiian Islands do share another common trait: they both receive many international visitors, putting residents at risk for infectious diseases such as measles.
Kauai is not immune, so to speak, from the vaccine refusal phenomenon. According to Dr. Berreman, the exemption rate varies greatly among Kauai schools—as high as 40% in some, as low as 3% in others. It follows, then, that the recent mumps epidemic affected the various districts very differently.
Dr. Berreman notes the advantages that a close-knit island community has in dealing with a public health issue such as vaccine-preventable disease. Community outreach workers are often people well known to the population, who can be more receptive to information given by someone familiar.
Epidemiologic and social considerations aside, island communities struggle with the same day-to-day issues as other rural practices. In Key West we have a 167-bed hospital with some adult specialty services, including a small adult intensive care unit. However, despite having the only labor and delivery unit in the Florida Keys, there is only a level 1 nursery, which houses newborns that are either healthy or have very minor issues. There’s no neonatal or pediatric intensive care, and inpatient pediatric services are limited. Similarly, according to Dr. Berreman, Kauai has no intensive care services for the island’s youngest patients, although there are inpatient facilities and a level 2 nursery (level 2 nurseries generally have a pediatrician or neonatologist in-house and can handle minor to moderate newborn complications).
Specialists, too, are at a premium. Although an island community would seem to be an ideal setting for the use of telemedicine to circumvent this dilemma, it has not been used in the Keys to any great degree, although at least one facility is planning to set up behavioral health sessions via this burgeoning modality. It may be gaining a little more traction on Kauai: Dr. Berreman notes, “We’re developing telehealth connections with genetics and neurology, as well as mental health and, possibly, post-op visits.”
For many services, then, travel is still necessary. And on an island, that generally means air travel for urgent medical matters. Although Key West is connected to the Mainland by 125 miles of road, access is not a guarantee. In addition to the usual accidents and road construction, periodically parts are closed off for festivals and other planned events (don’t, for example, try to pass during the 7-Mile Bridge Run in April). Even when road access is assured, transfer by ambulance, particularly for infants and children, is not always possible. Local vehicles do not transport very young children, even if medically stable and simply needing tertiary inpatient care. Pediatric inpatient facilities generally transport by helicopter, to the tune of tens of thousands of dollars. Although many insurers, including Florida Medicaid plans, cover this cost, there are still many uninsured families in the Keys—families where the breadwinner owns a small business, for example—that bear a significant portion of the cost.
For nonemergent specialty care, road access notwithstanding, there is the option of ground transportation in the Keys. Due to the cost of living here, a large percentage of infants do qualify for Medicaid. Since a trip to Miami is necessary for most specialty services, Medicaid will pay for transportation, usually by taxi. Similarly, Hawaii Medicaid will cover flights to Oahu for specialty services. In both cases, however, the time needed for transit plus the appointment means an unacceptably large amount of time off from work for parents who are trying to make ends meet in expensive parts of the country. In my Florida Keys experience, if a child isn’t visibly sick, many appointments—recommended screening hip ultrasounds for infants, for example—go unmade or unkept.
Kauai has neither road access nor helicopter transport to tertiary care facilities. What this means is an extra leg from, say, the hospital to the airport, and from the airport to an Oahu facility. Still, Dr. Berreman notes, that doesn’t quite compare to the logistic issues her patients faced on American Samoa. There, the only transport option was a commercial airline, which posed a major challenge if a lot of equipment, such as that associated with a ventilator-dependent patient, was along for the ride.
Of course, most people seeking medical care don’t have life-threatening conditions. But back to that question posed at the beginning: what if someone needs to be seen, and your island is cut in half? Dr. Berreman notes that just last year, Kauai experienced 50 inches of rain—a national record—followed by a landslide, that left no access for people on the island’s north shore. Evacuations did take place, but many on the more isolated side of the island wanted to stay in their homes, getting around by boats and surfboards. In order to serve these families, health care workers made their way across the divide and set up shop at a resort!
If the challenges are augmented on an island, so are the rewards. We’ll often see our patients stick around—in Key West, that often means that seniors bound for a four-year college complete the first two at Florida Keys Community College—and suddenly it’s the children we took care of that are now the adults that are mingling with us. Sharing island life with others is a very special feeling, even more so if you’ve contributed to their good health. And that’s maxing out what feels good about rural medicine.