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How One High-Risk Community In Rural South Carolina Is Bracing For COVID-19

Just as some demographic groups are more at risk than others of getting seriously ill from the new coronavirus, some parts of the country are more vulnerable to being hit hard by this pandemic. In places with more sick people, more people over 65 and fewer hospital beds per person, the health care system could easily be swamped, leaving residents who need hospitalization in even greater danger.

To find the areas at the greatest risk of being overwhelmed by a COVID-19 outbreak, we analyzed the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System, a collection of surveys that ask U.S. residents about their health,1 which allowed us to estimate what percentage of residents in a region2 were at risk due to their age or underlying health conditions. We then used Kaiser Health News’s data on the number of hospitals and intensive care unit beds in each U.S. county to find the ratio of at-risk residents to beds.

By that measure, one of the most vulnerable regions for which we have data is the Hilton Head Island metropolitan area, where about 63 percent of adults are at high risk of becoming seriously ill from COVID-193 and there are approximately 3,900 high-risk individuals for every ICU bed.

While the percentage of Hilton Head residents who are at risk is on the higher end of our data set, it’s still notably lower than the 70 to 80 percent we saw in several other areas we analyzed. But those regions had more health care facilities to serve those at-risk residents, while the Hilton Head area has only three hospitals and 28 ICU beds.

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Take Hardeeville, for example. It’s a small city in the Hilton Head metropolitan area, and in many ways it’s like any other rural area. Under normal circumstances, the city’s residents would be looking forward to an Easter egg hunt, golf and pickleball tournaments, proms and graduations. But the people of Hardeeville are particularly vulnerable to the new coronavirus. In the last decade, the city has seen a population boom, and many of those new residents are retirees, according to Hardeeville Mayor Harry Williams. The city’s large older population — the percentage of residents who’ve hit retirement age is nearly twice as high as the national share of people over 65 — may be cause for concern, as Jasper County, where Hardeeville is located, has only one hospital and four ICU beds.

While regular hospital beds can be converted to serve critically ill patients, it’s not easy to do because ICU beds require more equipment and specialized room layouts. Despite the difficulties, Coastal Carolina Hospital, the only hospital in Jasper County, has added beds for seriously ill patients by turning its observation unit into an ICU patient treatment area, according to hospital CEO Joel Taylor. Other hospitals are adding beds in temporary spaces like tents and trailers.

But it’s not just a lack of beds that can strain the health care system, noted David Wallace, a critical care doctor and professor at the University of Pittsburgh. Shortages of space, staff, medications and other vital resources are also a concern, and health systems in rural and poorer areas will be stretched the thinnest.

“There are going to be parts of the country that don’t even have the staffing even if you were able to ramp up your available resources, in terms of places to put these patients,” Wallace said. “If we were able to create more ICU beds and more ventilators and more [personal protective equipment], who’s going to be staffing those areas?”

Coastal Carolina Hospital is cataloguing what skills workers already have and cross-training them to work in parts of the hospital outside their normal assignments. This gives the hospital more flexibility in staffing, allowing it to do more with a limited number of employees by switching people to cover areas facing staffing shortfalls.

Hardeeville’s mayor is also worried about how easy it would be for the area to run out of other types of vital workers, like first responders. “Being in a rural area, we have a good staff, but it’s not a staff that can afford to have a whole shift wiped out because one person got sick and passed it onto the entire shift,” Williams said. “That’s a big concern of ours because we don’t have replacement numbers if our first responders get sick.”

Williams said the city got a shipment of additional masks and other protective gear for its first responders a few weeks ago, just as supplies were running low. So far, the city hasn’t run out, but it also doesn’t have a stockpile that would last through a big surge of cases.

As of Tuesday, there have only been 15 COVID-19 cases and one death in Jasper County, according to South Carolina’s Department of Health and Environmental Control. COVID-19 data should always be taken with a grain of salt, though, since tests have been so hard to come by. The closest testing site to Hardeeville is a hospital in a neighboring county, about 35 minutes away. Coastal Carolina is working on being able to test patients on site, Taylor said.

The state is encouraging residents to practice social distancing. But of course, staying at home is easier for some people than others. Williams said that in the gated communities where older residents often live, “Amazon is a way of life,” but that’s not the case for working families.

“Delivery services are not as effective as, let’s say, New York City,” Williams said. “For the working families that have to go to the grocery stores, go to Walmart for their everyday needs, those people need to go out. Those stores are open and they are taking precautions. The governor has limited the amount of people allowed in them, based on their square footage.”

But even those who have to go out are doing their best to keep infection rates down, Williams said. “Everybody’s pitching in.”

But more people may start leaving their homes soon. Shutting down businesses is having devastating effects on the economy, and the Hilton Head area is a popular vacation destination, so losing that influx of tourism dollars is an especially big blow for places like Hardeeville. South Carolina’s governor announced Monday to allow public beaches and some retail stores to reopen. But experts say relaxing social distancing measures too soon and before testing is widely available might result in another influx of cases, overwhelming the health care system and leading to even more deaths.

Find the full data set on GitHub to see if your area is included and how it compares with other areas.


  1. Based on the CDC’s list of underlying conditions that put people at higher risk of serious illness from COVID-19, plus the advice of experts from the Cleveland Clinic, the American Lung Association and the American Heart Association, we counted people as at risk if they’re 65 or older; if they have ever been told they have hypertension, coronary heart disease, a myocardial infarction, angina, a stroke, chronic kidney disease, chronic obstructive pulmonary disease, emphysema, chronic bronchitis or diabetes; if they currently have asthma or a BMI over 40; if they smoke cigarettes every day or some days or use e-cigarettes or vaping products every day or some days; or if they’re currently pregnant. We included every individual who meets at least one of these conditions but counted them only once each, so anyone with multiple conditions doesn’t get counted multiple times. We were not able to include a number of conditions for which we did not have location-based data from the BRFSS, such as liver disease, having smoked, vaped or dabbed marijuana in the last 30 days, and getting cancer treatment or being on immunosuppression medications.

  2. Specifically, the regions were micropolitan and metropolitan statistical areas and metropolitan divisions, which are groups of counties connected by an urban core. In total, we had data for 136 areas, and the U.S. has a total of 927 metropolitan or micropolitan statistical areas.

  3. According to 2017 BRFSS data, which is the most recent data available that breaks respondents down by metropolitan or micropolitan statistical area.

Likhitha Butchireddygari was a politics intern at FiveThirtyEight.