The hospital had already transferred out most of its patients and lost half its staff when the CEO called a meeting to take inventory of what was left. Employees crammed into Tina Steele’s office at Fairfax Community Hospital, where the air conditioning was no longer working and the computer software had just been shut off for nonpayment.

“I want to start with good news,” Steele said, and she told them a food bank would make deliveries to the hospital and Dollar General would donate office supplies.

“So how desperate are we?” one employee asked. “How much money do we have in the bank?”

“Somewhere around $12,000,” Steele said.

“And how long will that last us?”

“Under normal circumstances?” Steele asked. She looked down at a chart on her desk and ran calculations in her head. “Probably a few hours,” she said. “Maybe a day at most.”

The staff had been fending off closure hour by hour for the past several months, ever since debt for the 15-bed hospital surpassed $1 million and its outside ownership group entered into bankruptcy, beginning a crisis in Fairfax that is becoming familiar across much of rural America. More than 100 of the country’s remote hospitals have gone broke and then closed in the past decade, turning some of the most impoverished parts of the United States into what experts now call “health-hazard zones,” and Fairfax was on the verge of becoming the latest. The emergency room was down to its final four tanks of oxygen. The nursing staff was out of basic supplies such as snakebite antivenin and strep tests. Hospital employees had not received paychecks for the past 11 weeks and counting.

The only reason the hospital had been able to stay open at all was that about 30 employees continued showing up to work without pay, increasing their hours to fill empty shifts and essentially donating time to the hospital, understanding what was at stake. Some of them had been born or had given birth at Fairfax Community. Several others had been stabilized and treated in the emergency room after heart attacks or accidents. There was no other hospital within 30 miles of two-lane roads and prairie in sprawling Osage County, which meant Fairfax Community was the only lifeline in a part of the country that increasingly needed rescuing.

“If we aren’t open, where do these people go?” asked a physician assistant, thinking about the dozens of patients he treated each month in the ER, including some in critical condition after drug overdoses, falls from horses, oil field disasters or car crashes.

“They’ll go to the cemetery,” another employee said. “If we’re not here, these people don’t have time. They’ll die along with this hospital.”

“We have no supplies,” Steele said. “We have nothing. How much longer can we provide quality care?”

James Graham, with 41 years as a primary care physician, is the longest-serving member of the Fairfax Community Hospital staff.

Everyone in the room turned, as they often did, to the longest-serving member of the hospital staff James Graham, 67. He had worked as a primary care physician at Fairfax Community for 41 years, writing his cellphone number atop new prescriptions, making rounds while on dialysis through two kidney transplants, and sometimes hand-delivering medication to indigent patients out the window of his pickup truck. For much of his career, he had been on call as the only doctor in a town where the need for medical care continued to rise: Childhood poverty climbing up above 30 percent. Accidental deaths doubling in the past decade. Increasing rates of diabetes, heart disease, drug addiction and obesity.

Graham had been an honorary pallbearer at more than 160 of his patients’ funerals, watching the cemetery expand as Fairfax’s population declined from almost 2,000 to fewer than 1,300 through 40 years of attrition. The hospital remained the area’s largest employer, and the town had sunk more than half of its annual budget into legal fees to file a lawsuit against the hospital’s ownership company, hoping to retake control of Fairfax Community. There was still a chance the town could save the hospital in some form by partnering with a new management company, if the bankruptcy court would allow it. Fairfax’s vice mayor had promised employees he would come by at the end of the week to deliver an update, and possibly even paychecks if new management could be found.

“Maybe we’ll get good news,” Graham told the staff. “But we’re holding out for a miracle, and if some of you can’t afford to keep waiting and working for free, you can walk away now and nobody will blame you.”

He looked around the room as his co-workers stood in place. A call came over the hospital’s intercom. “Medical assistance up front,” a receptionist said. Graham waited for another second, until the silence sounded to him like a decision.

“Okay,” he said, moving toward the emergency room. “Let’s keep the doors open until someone tells us we can’t.”

Physician assistant Gari Owens, left, prepares to suture a gash that Lucian McKinney, 15, suffered in a fall while fishing. The scene was captured April 18 at Fairfax Community Hospital at the height of the hospital's funding crisis.

While making rounds at a senior care facility in Fairfax, primary care physician James Graham, 67, checks on resident Betty Perky, 84.

A tip collection at Treat's Coffee in Fairfax symbolizes the financial crisis that has gripped the rural Oklahoma hospital and many similar facilities across the United States. In many a rural community, the struggling local hospital is the sole source of health care for many miles around.

The hospital was the first building on the winding road into Fairfax, positioned atop the only hill in town, and for 65 years it had served a county that was larger in area than a few U.S. states. Patients came from all over Northern Oklahoma, traveling through cattle farms and across rolling prairie, sometimes driving up to an hour to reach their closest full-service hospital. It was a single-story building about the size of an average elementary school. An American flag flew above the open doorway into the main lobby, where the reception staff greeted most patients by first name on sight.

“A small community is only as healthy as its hospital,” read one sign near the entrance, but lately, that relationship in Fairfax and hundreds of other small towns had gone from symbiotic to ominous. Rural America needed more emergency care than ever before. Its hospitals were less equipped than ever to provide it.

In the past decade, emergency room visits to America’s more than 2,000 rural hospitals increased by more than 60 percent, even as those hospitals began to collapse under doctor shortages and historically low operating margins. Hospitals like Fairfax Community treat patients that are on average six years older and 40 percent poorer than those in urban hospitals, which means rural hospitals have suffered disproportionately from government cuts to Medicaid and Medicare reimbursement rates. They also treat a higher percentage of uninsured patients, resulting in unpaid bills and rising debts. A record 46 percent of rural hospitals lost money last year. More than 400 are classified by health officials as being at “high risk of imminent failure.” Hundreds more have cut services or turned over control to outside ownership groups in an attempt to stave off closure.

Driving in Fairfax, Graham passes shuttered businessess, silent markers of the towns steady decline.

Fairfax Community had survived a previous bankruptcy in 2011 and then passed through four outside ownership groups before being purchased in 2016 by EmpowerHMS, a Florida company that operated more than a dozen rural hospitals across the Midwest. The company promoted itself as “a savior for struggling rural hospitals,” but within months of taking over, its corporate office had begun defaulting on some of Fairfax Community’s bills and cutting its spending budget. Eventually, four of the company’s hospitals had shut down and nine more had entered bankruptcy, including Fairfax. It could no longer afford to provide X-rays or CT scans. No more remote monitoring for patients with irregular heartbeats. No more blood tests.

And now in came Dr. Graham, a day after the staff meeting, walking up to Steele in the hallway and waving another overdue bill.

“I hate to add another problem to your list, but this is a big one,” he said, handing her a letter. It said his malpractice insurance was three months overdue. He had 15 days to pay a minimum of $1,000 on the balance, or he would lose his insurance and his legal right to practice medicine in Oklahoma.

“Does it ever end?” Steele asked. She looked at the letter and thought about the hospital’s diminishing reserves in comparison to its mounting debts: $14,000 for overdue lab tests, $22,000 for leased machines, $9,000 for electrocardiogram readings, $70,000 owed to staffing companies and more than $600,000 in overdue payroll. In the billing office, there was a stack of certified letters and at least one lawsuit from a vendor demanding its money.

“I’m really no good to you without this,” Graham said. “You might as well let me walk out and retire.”

“I’ll take care of it,” Steele said. “We can’t do much without you.”

Graham had been talking about retiring for a few years, but he was one of just two physicians at the hospital, and he didn’t want to abandon his patients. He had tried recruiting his own replacement, but there was a doctor shortage of nearly 40,000 physicians across rural America, and he couldn’t find anyone willing to relocate to Fairfax. He’d tried mentoring promising students at Oklahoma’s medical schools, but they eventually chose to practice in bigger cities. He’d even tried submitting his resignation paperwork in 2018, selling his farmhouse, and moving 20 miles into the country with his wife, but his patients kept calling his cellphone, and there was no one else to treat them, so he continued returning to Fairfax to make rounds a few times each week.

The past 40 years had turned him into a seasoned generalist, accustomed to treating whatever emergency came through the hospital’s doors. One day it was a mother who’d gone into labor on a nearby road. The next it might be a critical gunshot wound, or an allergic reaction to a bee sting, or a panic attack, or a child with a cockroach stuck in his ear, or a pill seeker trying to hustle the ER out of pain medication in the middle of the night. “The ER doesn’t have a routine,” Graham liked to say, and for much of his career that uncertainty thrilled him, but now he felt something different whenever a new patient rushed in, a sensation closer to dread. “Do we have the supplies left to help these people?” he wondered.

A woman arrived with what appeared to be a broken arm, but there was no working X-ray machine to confirm it. “We have to sling it and send you on to Tulsa,” a nurse told her.

A child came in with his leg gashed in a fishing injury, but the hospital had run out of the correct-size thread to stitch it up. “This one will work just as well,” a nurse said, returning with a different-size thread from the emptying supply closet.

The doors opened again, and this time it was Cassie Fessler and her 16-year-old son, an elite high school basketball player who was bent over in the hospital lobby, complaining of chest pain and shortness of breath. His face looked pale. “My chest feels like it could explode,” he said, and two nurses took his vital signs while a lab technician attached electrodes to his chest to test his heartbeat and then immediately sent the results to a pediatric cardiologist in Tulsa.

Fessler paced the hospital hallway, and after a few minutes, Graham stepped out to walk with her. “Real sorry you’re dealing with all this,” he said.

“I saw your truck when we pulled up here and almost cried,” she said. “Thank God you were here.”

Graham had pronounced the death of Fessler’s grandfather at the nursing home 35 years earlier. He had worked with her mother, a nurse, and he had been Fessler’s primary care doctor for the past 40 years. The hospital had saved her 2-year-old daughter after she was stomped by a horse; it had treated another of her sons for acute cardiac distress. Now Graham told Fessler that her son’s heartbeat looked abnormal on the test. Fairfax Community didn’t employ any specialists trained in pediatric cardiology, and it no longer had money to pay for remote cardiac monitoring.

“We can helicopter him over to Tulsa in less than 25 minutes, and a cardiologist will be waiting,” Graham told Fessler, as she signed a few forms. “That’s really the best thing for him.”

Graham had heard doctors in Tulsa refer to Oklahoma’s rural hospitals as Band-Aid stations, places that offered a temporary salve before sending patients along to bigger hospitals for better care. The term was meant to be demeaning, but Graham sometimes used it with pride, because the temporary solutions at Fairfax Community were emergency blood transfusions, chest tubes, intubations, overdose reversals and several helicopter flights each month that saved people’s lives.

The helicopter landed behind the hospital, and two paramedics loaded the 16-year-old onto a stretcher to put him aboard. Fessler rushed to her car to drive 90 minutes to the hospital in Tulsa, since there wasn’t room for her in the helicopter. Graham watched as the helicopter lifted off, the thunder of its rotor shaking the hospital windows, and then he took out his phone.

“Hi, Cassie?” he shouted. “You drive safe, okay?”

Boarded-up store fronts, tattered signs and empty streets dominate downtown Fairfax in April. Like the community, the hospital is in a struggle for survival.

Nurses Karen Cook, left, and Carla Bartlett work an overnight emergency-room shift at Fairfax Hospital in April. Though unpaid, they continue to show up.

Graham, the primary care physician, photographs participants in a hat contest at a senior-care facility in Fairfax where he has several patients.

The ER emptied out. The hallways went quiet. The daytime staff went home, and what remained of Fairfax Community were two inpatients asleep in their rooms and a few nurses arriving for another overnight shift without pay.

“Well guys, Jamie and Katie just quit,” announced Donna Renfro, the head of nursing, coming into the staff room wearing sweatpants, slippers and a sweatshirt on what was supposed to be her night off. She had worked 150 hours in the past two weeks, but now the hospital’s staff had decreased by two more, and there was no one left to work the shift. “It’s just us,” she said, speaking to the entirety of the hospital’s remaining nursing staff, three nurses and three aides.

“I can’t exactly blame anyone for quitting,” said Karen Cook, an aide. “We’re probably the crazy ones, sitting up here every night, volunteering.”

“We’re going to have to start pulling 16 hours instead of 12,” Renfro said, looking at the upcoming staff schedule, where the same six names kept repeating. “I’m sorry, but I can’t see any way around it.”

“I’m guessing pay will stay the same?” Cook asked. She laughed and then went quiet. She was the primary earner in her family, and now she was running a tab at the grocery store and relying on friends to help pay bills. “I ride for the team,” she said. “Don’t matter what you need. I’ll be here.”

“You know I’m never leaving,” said Julia Smith, who had been born at the hospital and worked as a nurse’s aide for 38 years, earning $10.14 an hour.

“My parents say they’ll disown me if I quit,” said Monica Woods, a nurse at Fairfax for
18 years. Her mother had worked at the hospital for 32 years, and her father had been saved twice in the ER. “They can’t live here if there’s no hospital,” she said. “I’m going down with all of you.”

They were bound together by the lonely rhythms of a midnight ER, where on some nights they treated 10 patients and on other nights saw none. They sometimes took turns using the treadmill in physical therapy, watched movies or traded off smoking breaks to kill time, right up until the ER doors swung open after an overdose or a car wreck and they were suddenly administering CPR. “Why does it always have to be either insanely busy or dead?” Woods asked, at the start of a dead night, watching the clock until a call came in from Room 218.

“Everything all right in there?” Woods asked.

“Oh, I’m sorry,” said Carolyn Long, 76, one of the hospital’s two remaining inpatients. “I must have hit that button by mistake. Didn’t mean to bother you.”

“No bother at all, Mrs. Long. I’ll come right in.”

She was reclining in her hospital bed under a knit blanket, flipping channels on an old RCA television and forcing down another bottle of the vanilla smoothie that nurses delivered every few hours to help her gain weight. The entire staff at Fairfax Community called her Mrs. Long, because she’d taught most of them at the local middle school before retiring after 35 years. Now she’d been in Room 218 for two weeks, working with the physical therapist as she recovered from a blood clot in her heart. One of her assignments was to walk up and down the hallway, where she stopped every few steps to catch her breath and overheard snippets from the hospital staff. The lab was down from four employees to one. A technician had gone $100,000 into debt after having an emergency preterm birth, because none of the hospital’s employees had benefits or insurance.

Long had lived in Fairfax all of her adult life, and like most people in town, she felt some ownership over the hospital. She had given birth down the hall. She had watched both of her in-laws receive last rites in a room next door. Her husband’s construction company had poured the concrete for the helipad. She had served on the hospital’s community board in the 1970s and ’80s, when the hospital was ranked by state health officials as one of the best rural health facilities in Oklahoma, offering obstetrics, elective surgeries and a cadre of specialists who drove out from Tulsa for consultations each week. But then the oil fields dried up, costing the town most of its best jobs. Farming suffered through a drought, and Fairfax’s property valuations began a steady decline. Now, many shops on Main Street were boarded up, and the pharmacy had moved 30 miles to Ponca City. The school district had consolidated and gone to a four-day week to save money, and the middle school where Long spent her career was scheduled to close for good at the end of the year.

She’d tried to help Fairfax Community again from her hospital bed, asking friends to make donations. The town had established a general fund to help hospital employees pay their electricity bills. One rancher had come to the hospital with $1,000 checks for every remaining employee.

“How are all of you hanging in?” Long asked, when Woods stopped into her room.

“Isn’t that supposed to be my question?” Woods said, but she smiled and sat down for a minute anyway. “They’re telling us we might get paychecks tomorrow. If not, more people will quit.”

“How many people do you need to run a hospital?” Long asked.

“We’re going to find out.”

Signs of economic distress in the town that is home to Fairfax Community Hospital. The population has fallen from 2,000 to 1,300 in recent years.

Another morning, another staff meeting to see who was left.

“Do we still have dietary?” Dr. Graham asked.

“She just put in her notice,” said Steele, the CEO.

“How about receptionists?” Graham asked.

“If we get paychecks today, they’re staying,” Steele said. “If not, they’re gone as of this afternoon.”

“Guess we’ll wait and see what happens,” Graham said. The town’s vice mayor was coming in a few hours to deliver news about the future of the hospital, but rather than sit and wait, Graham walked out to his truck to take a drive through town. It was a flat, square-mile grid with no stoplight, and he knew almost every house and the traumas that had occurred inside.

He drove away from the hospital and into the adjacent neighborhood, passing the first home, with a collapsed front porch and windows blown out by a tornado. “I sat with that lady as she died four years ago, and now this house just rots away,” he said. He turned onto another block and drove past a bungalow where the owner had died of lung cancer at 58. Next was a suspected drug overdose. Next was a midnight heart attack in the bathroom, and Graham had checked for a pulse and then stayed to pray with the new widower until his children came from Wichita.

His cellphone rang, and he pulled over to answer it. “Hey, bud,” he said, and he listened as a patient described a pain that was rising from his stomach to his chest. “Trust me. I know history on you,” he said. “This medication can help, but it might make your depression worse. Make sure you go up there and see the counselors, all right?”

He hung up and continued down the block, past a house that had belonged to a young married couple. “I might have delivered both of them,” Graham said, and he’d remained their doctor until a few years earlier, when the husband shot and killed his wife in a domestic dispute and police shot the husband. They rushed him to Fairfax Community in critical condition, and Graham had been trying to drain fluid from his heart when he died on the operating table.

He rolled down his window and turned onto Main Street, where redbud trees bloomed outside abandoned storefronts, and his cellphone rang again. Another patient. More chronic pain. “I’ll call in a refill at the pharmacy,” he said. “Remember now, those old boys can’t just trust anybody these days. Make sure to bring your identification.”

Wild horses graze on the prairie near Fairfax. The community hospital serves a large rural area, with no other medical center within 30 miles by road.

He’d been offered easier jobs in Tulsa for better pay, but he’d grown up in another poor town with too few doctors, learning medicine as a teenager by administering his mother’s dialysis. Rural Oklahoma was down to one doctor for every 1,700 people, compared with one for every 400 nationally, and Graham had tried to compensate by opening a clinic downtown and treating uninsured patients free each month at a local church. He’d seen more than 10,000 patients over the course of his career, starting each new appointment with the same rule. “I can’t help unless you give me the truth,” Graham told his patients, and their truths were often depression, addiction, obesity, diabetes or lung disease.

He drove past the cemetery, where he’d buried his mother after treating her for kidney failure and his stepfather after treating him for lung cancer. He continued down a hill and idled for a minute in front of his ex-wife’s home, newly empty after she died three weeks earlier of unknown causes at age 62.

“I’m so sick of watching people die,” he said. “I keep trying to get out from under death, and I can’t do it. Who’s going to take care of these people?”

He looked up the road and saw one of his patients seated at his refinery business, 82 years old and still working full-time at a business that had shrunk over the years from 40 employees down to three. “What do you know?” Graham asked, pulling over to say hello, and the man tried to stand up to greet him but fell back into his chair. He had a pinched nerve in his back and pain his hip. Graham had been trying to get him in to see a specialist in Tulsa, but he was still waiting for an appointment.

“What are you taking for pain?” Graham asked.

“Nothing. I didn’t want to bother nobody.”

“You can’t bother me,” Graham said. “I’ve known you 40 years and never seen you like this. Let me go get my script.”

Graham leaned against the hood of his truck and wrote another prescription to dull the pain of rural Oklahoma. “Are we just getting older, or are we all getting worse?” he said, and then a few minutes later his phone rang again. It was a nurse at the hospital. The vice mayor had finished his meeting with lawyers, and he was on his way to Fairfax Community to update the staff.

“I’ll be right there,” Graham said, and he tore off the prescription, handed it to his patient and drove back up the hill.

Donna Renfro, Fairfax's head of nursing, tries to compose herself after an update on the hospital's financial situation in which staffers were told they would not immediately be receiving pay owed to them.

Fairfax Vice Mayor Charlie Cartwright comforts pharmacy employee Kathy Brock after briefing the hospital staff about the financial situation.

Hospital staffers are left shaken by the latest news about the effort to save the facility from permanent closure.

The original 60 employees on the hospital staff gathered in the main hallway. Some had already quit, others had stayed, and all of them were watching as the vice mayor walked through the door. Charlie Cartwright had his hands in his pockets, and he wasn’t carrying a bag. If he’d come with paychecks, they were still in his car. One employee knelt to pray. A few others slumped against the wall. “I’d rather not be here to see this,” Graham said, but he waited as Cartwright paced the center hallway, trying to compose himself.

“I promised myself I wasn’t going to come up here acting like a mess,” Cartwright said. His wife ran the hospital’s physical therapy department, and he had spent months fighting to get the hospital back under the town’s control.

“I wish I had better news, but I’m coming to you with a major problem here,” he said, and then he explained what he’d just learned from the lawyers. A bankruptcy court in North Carolina had retained control of the hospital, and it refused to give it back to the town. Another management group from Oklahoma had made a bid to operate the hospital, promising to restock supplies, issue paychecks and rehire at least some employees in an attempt to keep the hospital running, but any takeover was still weeks away. If the hospital closed even temporarily before then, state and federal laws would make reopening difficult, but Fairfax Community couldn’t afford to keep operating a full hospital, and the city had exhausted its budget on legal fees.

“We’re writing checks right now that our ass can’t cash,” Cartwright said.

The hospital doors swung open behind him. A man walked in complaining about a tick bite, still holding the tick. “Can someone tell me if this thing is going to give me Lyme disease?” he asked, and one of the staff members looked at the man’s arm as Cartwright continued.

He said he was aware of only one way for the hospital to survive until new management took over. “We become an empty shell,” he said. The hospital’s patients would have to be transferred out. All but a few employees would be laid off. Fairfax would close its hospital except for the ER, which would operate with minimal supplies and a skeleton staff — a nurse, an aide and a doctor on call.

“I need you all to tell me if this is what we want to do,” Cartwright said, and he looked over at Graham.

“It seems like the only way,” Graham said, and then he stepped into the center of the hallway to face the rest of the staff. “It’s been a big try, everybody,” he said. “Might not be over yet, and hopefully a lot of us will be back when this place changes hands. I know all of you want to help take care of these people. I know you’ll do it for free. You’ve proven that. But right now, the best thing a lot of us can do is go home. We’ll drop down to just an ER. We’ll take people’s vitals and send them on.”

“We’re a family,” said Renfro, the head nurse. “We’ll do whatever we have to.”

Employees hugged and began to clear out of the hallway as Fairfax Community emptied out. One inpatient was transferred to a nursing home. The other, Mrs. Long, was released into the care of a friend. The lab director locked the lab. The CEO shut off her computer. Graham walked to his truck and started dialing patients on his phone. “I’ll still be here,” he told them. “I’m always on call.”

He drove down the hill and away from the hospital, where life in a small town began and ended, and where on this night, what remained in the darkness were no patients, two nurses and a lighted red sign.

“Emergency,” it read.

Few lights are on at the nearly closed hospital. The helipad remains in use to evacuate even cases that once may have been treated locally.