

Natalie Pinner holds her 4-year-old son, Clayton, who survived a near-fatal allergic reaction in 2013 because his family got him to the emergency room in time. But Haywood Park Community Hospital in Brownsville, Tenn., for decades an anchor of the community, no longer exists. (Michael S. Williamson/The Washington Post)

This town of the Tennessee Delta, seat of a county that once grew the most cotton east of the Mississippi, relied for decades on a little public hospital built during the Great Depression a few blocks from the courthouse square.

The red-brick building was knocked down in the 1970s when a for-profit chain came along and opened a modern stucco hospital on the north side of town. There, thousands of babies were born, pneumonias and failing hearts were treated and the longtime family doctor across the parking lot could wheel the sickest patients who arrived at his office right into the emergency room.

But these days, plywood boards are nailed up behind the hospital’s sliding glass entrances. Black paint is smudged across signs over its doorways. The nearest ER is more than a half-hour ambulance ride away.

The demise of Haywood Park Community Hospital three years ago this summer added Brownsville to an epidemic of dying hospitals across rural America. Nearly 80 have closed since 2010, including nine in Tennessee, more than in any state but Texas. Many more are considered fragile — downstream victims of federal health policies, shifts in medical practice and the limited tolerance of distant corporate owners for empty beds and financial losses.

In every rural community, the ripple effects of a lost hospital are profound, reverberating beyond the inability of would-be patients to get immediate care. Many of the best jobs in town vanish. Local leaders trying to recruit new industry face an extra hurdle.

Haywood County’s budget has become a twisted mess as demand for the services of its ambulance authority has ballooned. “The emergency room now is the back of an ambulance,” said Bill Rawls, who grew up in Brownsville and was sworn in as its first black mayor the month the hospital closed.

“The emergency room now is the back of an ambulance.” Brownsville Mayor Bill Rawls

The town he leads is the epicenter of a dead-hospital zone in west Tennessee. Twenty-six miles nearly due south, the Methodist Fayette Hospital in tiny Somerville shut down eight months after Haywood Park. “This facility is permanently closed,” signs on its doors say. “Dial 9-1-1 in the event of an emergency.” The old operating room has been rented out for movie shoots.

About 60 miles southeast of Brownsville, McNairy Regional Hospital in Selmer closed last May. Vestiges of its care — a gurney, an IV pole, a crash cart — are strewn in the hallway near what was the emergency room. And within an hour to the north, Humboldt General Hospital and Gibson General Hospital also closed. Some outpatient services have come back at both — but no hospital beds.



Haywood Park Community Hospital in Brownsville, Tenn., closed three years ago, and the sign over its main entrance is covered in black paint. Plywood remains nailed up inside its sliding glass doors. (Michael S. Williamson/The Washington Post)

Brownsville’s hospital enjoyed a special legacy. When the original opened in 1935, a gift from a man who made his fortune in Nashville to his home town, Haywood County became one of the first poor counties in Tennessee with its own hospital. Today, the county remains so tied to its agriculture that family pictures are still taken in cotton fields. Its poverty also persists. More than 1 in 5 of the 18,000 people here live below the poverty line, with familiar consequences. Haywood ranks 90th out of Tennessee’s 95 counties for health, with obesity and diabetes especially common.

Together with Franklin Smith, Haywood County’s mayor for most of the past three decades, Rawls is struggling to bring at least an emergency room back to Brownsville. In his office in the small city hall adjacent to the fire department, he has a letter from a woman whose 8-year-old nephew was playing in the family driveway on a late winter morning last year when their Dodge sedan rolled backward, pinning him under a tire.

Without a hospital in town, she explained, “needless to say he did not make it.”

It is not rare for people to tell the mayor such stories, but this one came in writing, and he keeps it on his desk within eyesight. “What do you do about this?” Rawls asked. “It’s a heavy burden.”



Paramedic Dustin McKeel, left, and firefighter Jere Wright III tend to a woman who was injured in a crash on Interstate 40 in Brownsville, Tenn. People who need medical care these days must make a longer ambulance trip to Jackson-Madison County General Hospital since the hospital in Brownsville is closed. (Michael S. Williamson/The Washington Post)

***

On that spring day in 2014, Smith got a call from Haywood Park’s administrator hours before the official announcement. The hospital’s parent company, Community Health Systems of Franklin, Tenn., had filed paperwork with the state to shut it down in 90 days.

The news was stunning and abrupt but not a total surprise. For years, Haywood Park had been hemorrhaging patients and money. It had been years since an obstetrician was on staff, so babies were no longer being delivered. And as treatment for heart attacks, strokes and other life-threatening ailments had become more sophisticated, the hospital had become accustomed to stabilizing patients, then sending them by ambulance for more specialized care at Jackson-Madison County General Hospital, nearly 30 miles away. Eventually, more and more patients decided to skip the first stop and head directly to Jackson.

The year before it closed, ­62-bed Haywood Park admitted 245 patients — down from 917 three years before, according to data filed with the state. Dwindling popularity was not the only reason for the drop.

Federal officials who oversee Medicare had started sending auditors to make sure all hospital admissions were warranted, and hospitals did not want to risk admitting patients for whom they might not get paid. Then a new rule prompted hospitals to place more older patients on “observation status” for brief stays — put in beds but not officially admitted, which meant lower government reimbursement.



Haywood County paramedic Chris Milton tries to comfort Kay Otts, who had just suffered back and neck injuries in a car crash, as an ambulance races her to the nearest hospital nearly 30 miles away. (Michael S. Williamson/The Washington Post)

One other financial blow: The Affordable Care Act curtailed hospitals’ Medicare payments on the theory that more patients would be insured. Even if the law disappears, predictions vary on whether Republican health-care proposals being contemplated in Washington would help or hurt.

The Affordable Care Act has not gained much ground here. In 2016, just 664 Haywood County residents bought health plans through its marketplace for people without coverage through a job. By one estimate, 2,200 residents would qualify for Medicaid benefits if Tennessee expanded the program under the law; the Republican governor tried but was rebuffed by the more conservative legislature.

Near the end, more than a quarter of Haywood Park’s charges were for “self-pay” patients who lacked health insurance. Haywood Park’s losses grew from $4.2 million in 2010 to $6.6 million in 2013, the data show.

“They tried everything to keep it open,” said Clarey Dowling, who arrived in Brownsville in 1980 as a fledging family practitioner and never left. Over the years, he was Haywood Park’s medical director and a member of its board, and the staff knew it was lunchtime when he walked across the parking lot from his office to the hospital each weekday to check on patients.

When the hospital closed, Community Health Systems announced it would keep an urgent care center there. Dowling added Wednesday afternoon and Saturday morning shifts to his work schedule to help out. Yet five months later, the company announced that the urgent care was not drawing enough patients. By the end of January 2015, it was gone, too.



Carolyn Freeman, 86, who lives in an assisted-living facility, has been taken to Jackson-Madison County General Hospital four times since December for fainting from low blood sugar. The ambulance trip to Jackson is at least 30 minutes longer than a trip to Haywood Park Community Hospital was. "Oh, I do miss it. It was such a good feeling just having that hospital,” she said of Haywood Park. (Michael S. Williamson/The Washington Post)

***

On the morning of the hospital’s last day, Natalie Pinner drove to its parking lot, turned off her car and prayed.

Exactly a year earlier, she had been with her parents, who live next door along a country road that bears the family name. Her father and husband were grilling. She was in the kitchen with her mother, a sister and her son, Clayton. It was 5 p.m., and the ­15-month-old was hungry, so she gave him some peanut butter on a cracker. He touched it to his lips, not even taking a bite, and red welts immediately popped out on his face. He started gasping for air.

Her sister, a nurse, knew they needed to get the little boy to the hospital, pronto. They piled in the car and, blaring the horn and flashing the lights as if it were an ambulance, raced the eight miles to Haywood Park in less than six minutes. Clayton’s eyes were rolled back as Pinner ran in with his limp body. The ER doctor said his airway was closed and his oxygen level so low that he might not survive. But shots of epinephrine gave the staff enough time to summon a medical helicopter that flies the most desperately ill or injured patients to Memphis, about 60 miles away.

Pinner, a part-time teacher, believes her son would have died if they’d had to drive to Jackson. When she heard the news about Haywood Park, she sent letters that begged the staff to keep it open. And when that failed, she marked the anniversary of Clayton’s emergency by praying for the safety of her town.

Some effects of the hospital’s absence are inconveniences that nonetheless matter. Crestview nursing home in Brownsville often has to scramble when frail residents must be taken to the dialysis center down the street. The ambulances are usually too busy.

Other events are crises. Phyllis Cozart worked at Haywood Park for 21 years and was its human resources manager when it closed. Last August, on a humid, 100-degree morning, she and her husband were working in their garden when Charles collapsed. If the hospital were still there, she thought, she could have forced him to go to the emergency room. But he refused to go to Jackson and miss an afternoon of golf. By lunch, he seemed to be okay. He headed out.

It would be his last golf game. At 8:30 p.m., he was sitting in his favorite recliner when his wife looked over and noticed that his smile was crooked. Immediately fearing a stroke, she asked her husband to raise his arms, right and then left. His left arm would not move.

By the time the ambulance answered the 911 call and got Charles Cozart to the Jackson hospital, his carotid artery was 100 percent blocked. He was there for a week, then at two facilities for rehabilitation, before finally coming home in December.

“My left arm isn’t doing anything,” Cozart, 73, said late last month. “I can walk a little, but it’s kind of slow.”

He sometimes visits the golf course, riding in his cart to watch his friends play.



If Haywood Park Community Hospital had still been open in August, Phyllis Cozart would have insisted that her husband, Charles, go to the emergency room after he collapsed in their garden. Hours later, he had a major stroke. (Michael S. Williamson/The Washington Post)

***

For such a small, obscure place, Haywood County has a rich heritage. It stands out in civil rights history as the place where the first NAACP member was found murdered. During the 1960s, it was the site of “tent cities” erected by black tenant farmers evicted from their land by white owners for attempting to vote.

In cultural history, the area is the childhood home of singer Tina Turner, author Alex Haley and blues pioneers including “Sleepy” John Estes.

Brownsville Mayor Bill Rawls still remembers the day he had to order the hospital signs removed from Interstate 40 so travelers would not continue to think that emergency care was available. (Michael S. Williamson/The Washington Post)

It was that same spirit — of managing to make something from nothing — that fueled the determination of Brownsville’s leaders to replace the shuttered hospital or at least reclaim an emergency room. Smith, the county mayor, and Rawls, his city counterpart, met with several health-care systems in Memphis. They pointed out that Haywood County is the site of Tennessee’s largest “megasite,” a 4,100-acre parcel where the state has been trying to recruit an auto assembly plant or other major industry. If the site is filled, they said, the population will swell and there will be plenty of patients.

So far, they have been rejected.

Last fall, state officials began talking of spreading $1 million in leftover disaster relief aid among four counties that had lost their hospitals. Three were in west Tennessee: Haywood and the counties just to the south. But last month, as Haywood was making plans to buy land for an emergency room, the state decided to send the money instead to help Gatlinburg, at the edge of the Great Smoky Mountains, recover from deadly wildfires.

“Every time we get two steps forward,” Rawls said, “we get knocked back.”

A year after Haywood Park closed, Rawls started a program he dubbed “Healthy Moves.” It urges Wednesday night Bible study groups to do five laps around their churches, encourages baked chicken — not fried — at funerals and promotes morning walks around the high school track with a local radio DJ. If Brownsville cannot depend on a hospital, the mayor figures, its people have to become healthier so they need less care.

And as it became clear that no bigger hospital system was interested in the area, a county task force went to Nashville to meet with a lawyer specializing in health care. The only solution, the lawyer advised, was to expand the ambulance service to help get patients out of town.

Despite their strapped budget, the county commissioners added seven paramedics and advanced emergency medical technicians. Haywood went from two ambulances available at any given moment to three.



A view of the empty entry area at McNairy Regional Hospital in Selmer, Tenn. (Michael S. Williamson/The Washington Post)

The typical call, 30 minutes when the hospital was open, is now 2½ hours. Even with the extra ambulance, there are times when all are on runs outside the county. A woman who fell and broke a hip not long ago waited in her driveway for an hour.

David Smith, the ambulance authority’s director, had expected such complications. What he had not anticipated was how many people would call an ambulance, be treated in their driveways and then refuse to be taken to Jackson or Memphis. The ride is “a one-way ticket,” as one paramedic put it. That’s a deterrent; patients have to find their own way home.

But unless a patient is transported, neither Medicare nor Medicaid will pay for the ambulance run. The ambulance authority sends out bills, but in such a poor county, “there is no way to turn them over to collections,” Smith said. Some people bring in $5 or $10 when they can. In 2016, the ambulance service wrote off more than $1 million in unpaid charges.

“It has broke this county,” he said.

With no hospital in Haywood and 535 square miles to cover, the crews have been stepping up their protocols. They can insert chest tubes, start intravenous antibiotics and intubate patients to help keep airways open.

This move toward more advanced care in the back of ambulances is a reason the Tennessee Ambulance Service Association named Haywood County’s emergency service the best in the state in January. The imposing cut-glass trophy was bittersweet.

It arrived as the county mayor was losing a battle with the county commissioners to raise taxes for a third straight year — to prop up the budget that the 911 calls have been eating away.

So the county is cutting the ambulance service staff. By July, the number of ambulances at the ready will go back from three to two.