CARROLLTON, Ala. — Annie Jackson can't know whether her sister Grena Prude might have survived had an ambulance been more readily available when she went into cardiac arrest on May 10. But Jackson is convinced her sister would have at least had a chance.

Prude, 55, died at the steps of Carrollton City Hall, less than a half-mile from her county's only ambulance station. When someone called 911 to get her help, two ambulances were on duty: One was transporting a patient to Tuscaloosa, Alabama, 45 minutes away, and the other a patient to Columbus, Mississippi, a 30-minute drive.

"It was a horrible situation," said Vicky McCrory, supervisor of the nonprofit Pickens County Ambulance Service, but not an isolated one. There have been multiple similar tragedies.

That single ambulance station in Carrollton serves all of Pickens County, dispatching one and sometimes two ambulances to serve just under 20,000 residents spread across 900 square miles. The farthest reaches of the county line are 25 to 30 miles away on two-lane country roads.

In rural areas where hospitals have shuttered, like Pickens County, the nearest surviving facilities are long drives away, ambulance coverage is sparse, and residents in the throes of medical emergencies often find their situations even more precarious.

In May, the rural health research and policy centers released the results of an effort by the Maine Rural Health Research Center to document coverage gaps in the availability of ambulance services across the country — what the researchers refer to as "ambulance deserts." They define those deserts as places where people live more than 25 minutes from the nearest station.

The study found that in the 41 states for which data was available, 4.5 million people lived in an ambulance desert. Six in 10 lived in the South. Alabama had 315,000 people living at such a distance, ranking second highest behind North Carolina.

But a closer look into emergency services in Pickens County reveals a grimmer situation. In March 2020, the 56-bed Pickens County Medical Center shut its doors, with administrators citing an unsustainable financial situation and a declining patient volume.

Those living along the periphery of Pickens County must wait nearly a half-hour for an ambulance to arrive. Patients must then ride up to an hour to reach a hospital, in either Tuscaloosa or Columbus. 

State Route 86 runs through downtown Carrollton, past the courthouse and City Hall. To the north are the tapering hills of Appalachia; to the south, the Black Belt region.

"Everybody here knows everybody," said Terrence Windham, mayor of Aliceville, a town roughly 10 miles south of Carrollton. And, seemingly, everyone has heard of the death of Grena Prude.

Julia Boothe is a longtime family physician in the town of Reform, situated about 10 miles north of Carrollton, and a recent president of the state medical association.

Boothe said it's not uncommon for people to decide there's no point in calling 911. Some instead show up in her office in a condition well beyond what "a family medicine practice in a rural area of 1,500 people" is equipped to handle.

"People don't understand the severity of what's going on" in these rural areas, she said.

At one time, the county had the resources to deploy three ambulances.

"Now," McCrory said, "we're lucky to have one unit." The closure of the hospital, she said, has meant a loss of some $250,000 a year in revenue for the ambulance service.

Further, Boothe said, "the stress and strain" of working in the county make it difficult to recruit emergency medical crews — not to mention health care providers of any specialty.

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This critical shortage of services reflects what's happened to so many rural communities across the U.S. after decades of dwindling resources.

In 1979, when Bill Curry returned home to Pickens County to practice medicine, funeral homes provided the only ambulance service.

"A hearse, literally, would come to the scene of an auto accident or to somebody's house or wherever there was a need for somebody to get transported to a hospital," recalled Curry, now a professor emeritus of medicine at the University of Alabama-Birmingham. "The training was pretty minimal, and the interventions were almost none. It was just pick up and go."

"When we developed the hospital, we said, 'Well, we really need a modern ambulance service, and so that's how we came up with what they have today," Curry said.

James Parker grew up in Pickens County; his dad ran a feed-and-seed store and raised cattle. Parker had mentors growing up, including Curry, who were prominent in the community and pillars of the hospital. They allowed him to shadow them and nudged him into medicine. He returned home after graduating from medical school in 2000 and has been practicing there since. He laments the loss of the hospital.

"You know, folks love to call a little hospital a band-aid station, but that's a big band-aid that worked," Parker said. "So many success stories of our little hospital."

But with advances in medical technology — allowing more procedures to be performed on an outpatient basis — and an unfavorable payer mix, the old model was deemed no longer feasible.

Community leaders believed they had a viable plan to revitalize the hospital. "I thought it was an excellent option," Boothe said. They requested $10 million from the state legislature — which then became $8 million — to reopen the emergency room and operate an adolescent mental health facility that would serve kids from across the state.

Here, it seemed, was the answer to a need for Pickens County and beyond. Boothe has had young patients who "sat in emergency rooms for over seven days waiting on an admission to an adolescent bed." Some ultimately had to be transferred out of the state.

The $8 million was still in the state budget when it passed the House in April, but, in the eleventh hour, the Senate scuttled the cash infusion.

The issues related to the need for rural emergency care highlight another concern. The authors of the May report on ambulance deserts wrote that the "declining numbers of rural hospitals and ambulance services imply that remaining ambulance services are being tasked to play a greater role in delivering more sophisticated emergency services."

"Ambulance services were never intended to take the place of emergency departments," McCrory said. "I just feel like health care all the way around is failing here, and in other rural areas, too."

The researchers also noted the fragmented nature of ambulance services, particularly in rural areas.

Boothe talks of a potential solution whereby three ambulance stations would be spaced across Pickens County and Lamar County, on its northern border. But that's not an easy maneuver.

"Of all the poorly designed aspects of our health care system," said Alan Morgan, CEO of the National Rural Health Association, "EMS is tops."

On a sweltering day in late July, several dozen Pickens County residents and officials traveled 2½ hours to the Alabama Statehouse in Montgomery. They stood on the steps to protest lawmakers' decision not to fund their hospital.

Aliceville Mayor Windham was among them. There's a sense in Pickens County that rural communities such as his don't show up on the radar in Montgomery, he said. He and his neighbors' ongoing mission "is to let the Alabama Legislature know that we are real, live human beings — and we are really suffering."

Morgan, of the rural health association, has witnessed the ripple effects of the loss of essential rural health care services — the consequences for a community's health and the health of its economy. "Rural health care," he said, "is like a tundra. You trample on it, it's really tough to get it to come back."

Annie Jackson joined her neighbors on the steps of the state Capitol that July morning. After traveling hours away from home, she stepped off a chartered bus in downtown Carrollton, less than a hundred yards from where her sister Grena died. She paused and pointed up the road toward the nearby West Alabama Animal Hospital.

"We have our animal hospital up here," Jackson said. "The animals have a hospital. But we do not. What does that say for us?"

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.