People in poor and rural areas are left with little access to care, with chronic diseases unchecked and a higher risk of complications if people have Covid-19

Camden might seem like a strange place for a coronavirus outbreak. It’s a small, historic city in central South Carolina – just over 7,500 people. It’s neither densely packed like New York nor economically decimated like Detroit. One of its main industries is tourism, with people visiting to see Revolutionary War re-enactments and the annual horse race every spring.

But on 6 March the first Covid-19 case was confirmed positive – an elderly woman whose family had visited her after traveling to Europe. Soon after that, Camden had the fastest-growing number of cases, and deaths, in the state. At one point it had the most coronavirus cases per capita in the country.

While Camden’s local officials worked relatively quickly to try to contain the virus, experts say it’s not surprising that the city was caught unprepared. The South Carolina government has systematically dismantled public health infrastructure for over a decade – from reductions to the health budget to diluting a minority health program. The state’s response to the pandemic was one of the slowest in the country.

“I think it’s an interesting dynamic – it’s state, local and federal,” said state senator Vincent Sheheen, who represents Kershaw county, where Camden is the seat. “I think that’s where the problems come in: who is responsible for what? That has not been well defined, and it wasn’t well defined before the crisis.”

This disconnect was clear starting with the first Covid-19 test. When health workers suspected the Camden woman of having the virus, the state refused to process a swab sample, Sheheen said, because she didn’t meet the criteria. It was days after the patient was admitted to Kershaw Health, the county’s only hospital, that the state’s department of health and environmental control (DHEC) agreed.

For a few days, as Camden city officials worked to formulate a plan and shut down public events, people still went out to restaurants and events. An Irish Fest, being held that weekend, took place. So did a funeral, which tracing later linked to six deaths in the city.

“No one took it seriously,” said Nyasha Green, a 30-year-old Camden native who now lives half an hour away from her parents in Columbia. “They should have quarantined people already.”

By the next week, however, the city had shut down public gatherings, and was working to close the area’s many churches. Dozens of businesses closed their doors, and city council members urged people to stay home. By 14 March, Camden shut down schools, and some days later, enforced a 10pm curfew.

“We started taking precautions before the state had a chance to lead,” said Mel Pearson, the city manager. “We knew this was a risky virus.”

Facebook Twitter Pinterest An empty church stands in a rural and economically distressed part of Camden, South Carolina. ‘The standard of living is low. People definitely wait until things get worse. Most primary care happens at the ER when they can’t turn you away.’ Photograph: Spencer Platt/Getty Images

As local testing drives began, Sheheen said the state eventually did send health department officials to embed in the hospitals and city government, but made it clear they didn’t have the capacity to investigate the outbreak.

“Very early on I was calling other hospitals asking for masks and swabs,” he said. “But it’s not a good situation when your state senator is calling around.”

It would still be weeks before South Carolina’s governor, Henry McMaster, issued statewide stay-at-home orders on 6 April. By then, Camden had more than 170 positive coronavirus cases, and a handful of deaths. Neighboring counties, such as Richland, were now faring worse.

We see this combination of higher rates of chronic conditions combined with poor access in the state

South Carolina has been a consistently Republican state for decades. It has also become increasingly focused on shrinking the government – cutting the public sector in favor of privatization – a key characteristic of America’s fiscally conservative politicians.

Governor McMaster is widely known for curbing taxes and public benefits like pensions for government workers. But cuts to the state health department and infrastructure have left people in poor and rural areas with little access to care because of physician shortages and hospital closures.

“Haley and Sanford have been gutting our state health agency for over 10 years,” Sheheen said of the two former Republican governors. “It’s no surprise doctors are left reusing their masks.”

The state’s most recent three leaders, including Governor Nikki Haley, who later joined the Trump administration, chose not to expand the Medicaid program under the Affordable Care Act, which would have extended public health insurance to thousands of working-class families.

The result was that more people remained uninsured, and had less access to medical care. In Camden, about 10% of the population has no health insurance, higher than the national average of about 8%.

A lack of insurance also means people have gone without treatment and are more likely to have underlying health conditions, said Samantha Artiga, a director of Medicaid and disparities teams at Kaiser Family Foundation, a not-for-profit research organization. South Carolina is among the US states with the highest rates of heart disease, respiratory issues and strokes.

“We see this combination of higher rates of chronic conditions combined with poor access in the state,” Artiga said. “That leaves a population at higher risk of experiencing complications if they have Covid.”

While the government has applauded the expansion of private health companies like Prisma Health, at least six rural hospitals have closed down since 2010. And legislators have slashed millions from DHEC - including a $16 million cut in 2018 – and curbed funds for safety net clinics.

The workers that interface with elderly people, or who are caregivers are poor people

Cheryl Armstead, a psychology and public health professor at the University of South Carolina, said the state’s ruthless approach to public health has had tangible consequences on its most vulnerable communities during the pandemic.

“Camden is a small town, denoted by the haves and have-nots,” she said. “The workers that interface with elderly people, or who are caregivers are poor people.” About 14% of residents in the city live in poverty, according to the census, and a disproportionate number of poor people are black.

Armstead said black communities are less likely to trust the government, an issue further tested during the Covid-19 crisis. In recent years, South Carolina also weakened a vaccine program previously under the office of minority health.

Furthermore, the persistent trauma around the Tuskegee experiment, a racist government project, and the Henrietta Lacks case, where a black woman’s cells were used without consent, still inform people’s decisions around healthcare in the south. Black church leaders have had to step in to relay public health information.

“I think a sense of fatalism has occurred,” Armstead said of black people in South Carolina. “The feeling is that they won’t get equal healthcare.”

Who is responsible for what? That has not been well defined

Across South Carolina, the counties that did not act as quickly as Kershaw are now dealing with an onslaught of cases. The state had 4,300 cases as of 18 April, and other cities are grappling with a shortage of test kits. Hospitals beds are half full in the state so far, and several smaller hospitals have used all of their ventilators, Sheheen said.

As of last weekend, Covid-19 rates in Camden seem to be slowly decreasing with just a couple of new cases each day. Pearson, the city manager, said people were still worried, but that local efforts had been largely successful. “It’s trending down now, which is a good sign,” he said.

But the city is still carefully tracking the number of cases before making any plans to reopen. Pearson said he was hoping that eventually, Camden would be able to attract visitors again, drawing tourism to the historic town.

Until then, Green said she is regularly checking on her family, including her parents, who are in their 60s.

“I try to make sure they have everything they need,” she said. “I drove down there and put toilet paper on their porch.”