Critical care: it's what these small hospitals provide the economies of remote, rural counties.

• Author: Martin, Edward
• Position: FEATURE

Muffled voices and footsteps mark the Monday morning frail of a half-dozen hospital staff working their way down a hallway, stopping at one room after another. At the cluster's center is Phillip Harris, a graying doctor in blue oxford-cloth shirt and khakis. He pauses at an open door to study the chart in his right hand. "She came in last night?" A nurse nods. "That's right, late."

A figure appears, teetering on a cane and steadied by another nurse. "I was woozy" she says weakly. Harris sizes her up: barely 5 feet tall and frail as a whisper, her snowy hair still permed for church. She wears a floral-print blouse and creased slacks, the kind of outfit elderly country women keep in their closets--"just in case," as they say. "We're going to try to help you with that," he says softly. Members of the group introduce themselves. "I'm James, the respiratory therapist. If you have trouble breathing ..." "I'm Betty, and I'm going to be your nurse ..." Melissa comes last. "I'm going to help you when you go home ..." The possibility she won't is left unspoken. Outside the window stand Three Rivers Health and Rehabilitation, a nursing home, and Windsor House, for those with dementia and Alzheimer's disease.

The mood is brighter in another room. "You're going home today?" The patient, bedridden but freshly made up, smiles and nods. "When you came in, you had too much fluid," Harris tells her. "We've gotten rid of that. Your heart's beating fine." Helen Bernice Whitley, 83, stirs under the sheets. A retired bookkeeper and office manager, she has congestive heart failure. Daughter Jacquelin Nicholson is at her bedside. "A real blessing," her mother calls her.

Then, that quickly, it's over. Rounds finished in 25 minutes, the group disbands. Harris, a family practitioner who is Vidant Bertie Hospital's vice chief of staff, has seen today's patients--all five. Last night, the emergency-room physician sent another one, who had come in gripped by a worsening heart attack, straight to Greenville, 40 miles away. Vidant Bertie Hospital, North Carolina's smallest, has six beds; Duke Medical Center, the state's largest, has 957. Just as in Durham, patients come here sick and injured, get well and go home, and some die. But medicine in Windsor, population about 3,400, is a world apart.

As a business, the hospital is barely a blip in the state's $70 billion-a-year health-care economy, though the 128 people on its $9 million annual payroll make it one of Bertie County's largest employers. That's the case in many rural counties, where one of three North Carolinians--about 3 million--live. At Bertie Vidant, care is intimate, attentive and personal, but its providers face problems nearly imponderable in big cities. Many patients are dirt-poor, some living in singlewides rusting in piney woods or houses without indoor plumbing. Some can't read well enough to take the prescriptions Harris, 58, writes for them. Others cannot get them filled because, back home, the nearest drugstore is 25 miles away. "If they can find someone to take them, that's 10 or 15 bucks," he says. "That's a lot of money here." Diseases controllable elsewhere kill people here.

In 2001, the tiny hospital became the nation's first to open under a new federal law. Like hundreds of others in places like this, it was at death's door, and if these hospitals closed theirs, millions of rural Americans would be without care. Called a Critical Access Hospital, this one became a national model for the genre. The designation allows it--and 21 other of the 138 hospitals in the state--to be paid a rate based on the actual cost of treating Medicare patients rather than the fixed fees larger hospitals get. That and its affiliation with Greenville-based Vidant Health, the largest health system in eastern North Carolina, saved its life.

But laws can't change demographics, and business models don't redraw geography. "It's the buckle of the Stroke Belt," says Paul Cunningham, dean of Brody School of Medicine at East Carolina University in Greenville. He's referring to a swath of the South where the death rate due to cardiovascular disease is 10% higher than the national average...