CLARKSDALE, Miss. — The nation's poorest state, Mississippi, was hit hard by the pandemic, often holding the dubious ranking of having some of the country's highest case numbers and deaths.

"I compare Covid in Mississippi to Katrina in New Orleans," says Dr. Mary Williams, a licensed nurse practitioner who owns Urgent and Primary Care of Clarksdale. "You saw how the hurricane did. Covid did that to us."

The virus brought her small clinic in the rural Mississippi Delta to the brink. She had barely been open two years when the pandemic and lockdowns hit. Some days she had to work for free just so she could pay her staff.

"The pandemic got me to a point where, at the end of the day, all I could do is go home and shower and fall into bed. Because everything in me had been drained," Williams says.

Nationwide, health care workers are burned out. In a recent survey, three-quarters of workers in rural or underserved communities reported feeling close to wanting to quit. In rural America, this adds to an already long list of strains on small town providers. Before the pandemic, there was already a persistent shortage of primary care providers in states like Mississippi.

Health Care in rural America struggled long before the pandemic

Williams says she has been able to weather the crisis for now, though, thanks to a combination of loans, federal pandemic aid and a lot of grit, dedication and hard work. After the vaccines came online, she was able to start hiring more nurses and some of her furloughed staff came back. She's now at eight employees.

Her clinic is seen as a lifeline. Last year, it served close to to a third of Clarksdale's 15,000 or so residents. Recently, two primary care doctors moved out of the community, creating yet another gap in access to care.

"Health care in rural areas is suffering," Williams says. "We need twice as much [help] as the urban leaders do, because we don't have the large hospital right around the corner."

Indeed, the health disparities in the Mississippi Delta are real. Chronic problems include high diabetes rates, and among the nation's highest heart disease death rates. But Williams is also quick to beat back stereotypes.

"Sometimes with misconceptions in a rural area, you automatically think these are people who are uneducated, who can't read or write," she says. "But that's not true."

And while per capita income is only $19,299 in Clarksdale, more than half of Williams' patients get insurance through their private employers, and most of the rest she sees have Medicare or Medicaid.

So there's enough money that she could afford to hire two more nurses, if she could find them.

"I'm lost for words because I want to help everybody, and I know I can't," Williams says. "I want to find someone who can come here and provide the patients a great level of care that they deserve."

Burnout is real and making things worse

Since the pandemic, it's estimated that more than 300,000 health care workers have left their jobs, many exiting the sector altogether. Rural hospital closures have only accelerated too, especially in states like Mississippi that didn't expand Medicaid.

"They're doing everything they can to try to keep care of the people who are part of their community, including neighbors, and basically getting burned out and leaving the profession," says Brad Gibbens, acting director of the Center for Rural Health at the University of North Dakota.

Gibbens says combating burnout, stress and the "great resignation" is going to take creativity, especially since there is no clear indication that federal lawmakers will intervene to help rural providers stay afloat.

He says some small towns are looking at pooling money from various community sources to help nurses out with childcare, housing or other possible incentives that might offset the lower pay and long hours. He says sometimes, even smaller tokens of appreciation might go a long way — such as restaurant or spa gift certificates.

"The thing that people in Clarksdale would have to consider, if the NP who has this clinic just gets so burned out that she has to walk away, what will be there?" Gibbens says. "So they have to think about, what can we do to sustain what we have and how do we help it?"

Accepting that you can't help everybody

In Clarksdale, Mary Williams feels lucky to have kept all the staff she has, especially as costs for labor and supplies have continued to go up amid record inflation.

To address burnout, her staff tries to schedule fun things like a dinner or movie night. The clinic will also soon have a telehealth service and they're now closed on Fridays, giving her and her staff a longer break for the weekend.

She also had a realization recently.

"I feel like I can't [take a break], but if I know if I don't, then it's going to be worse," Williams says. "If I don't take a break, instead of turning away two or three people per day, I'll soon be turning away twenty or thirty."

One big thing keeping this clinic hanging on, she says, is her staff, who when they can, try to have fun and make jokes.

One recent afternoon, during a break in patients, nurse Cassonya Lampkin and community health worker Lisa Dixon broke out in laughter while trying to explain how they've kept going these last two years. They say they have a great rapport and try to stay upbeat. While the pay may be better in some cities like nearby Memphis, Dixon said there are rewards to working in a small town where everybody knows everybody: "In most cases we're all they have, they don't have anyone else."

Burning out, Lampkin adds, will only hurt patients and erase the slow progress they've made in trying to chip away at the chronic health disparities and gaps in care in the Mississippi Delta.

"Try to encourage yourself that what you're doing does matter, it may not seem like it, but it does, what you do does matter," Lampkin says.