HAZARD, Ky. — From a strip-mined bluff at the edge of this town of 4,800, nestled in eastern Kentucky's mountains, you can see one of the most concentrated and diverse sets of medical facilities in rural America: a general hospital, a psychiatric hospital, a university-based rural health care center and clinics for primary care, cancer, urology, cardiology, addiction and ear, nose and throat problems.
Yet Hazard, which was a coal boomtown for decades, rests at the center of the worst life expectancy in America, according to a report last year by the American Human Development Project. Diabetes, asthma, lung cancer and emphysema, heart disease and lifelong obesity are all problems encountered in the waiting rooms of these facilities.
Very little is likely to change here under any of the current legislative initiatives focusing on overhauling health care, say experts such as Dr. Forest Callico, the former director of the Appalachian Regional Hospitals and a rural health adviser to both the Clinton and second Bush administrations.
"It's not all about the money," Callico said. "We have to transform the way we take care of people."
Bad as most health measures appear in lower Appalachia, Callico says, there are enduring models in places such as Hazard that could prove instructive to rebuilding healthy communities across the nation, both rural and urban.
Gerry Roll, who reached adulthood as a homeless, single mother, helped organize Hazard-Perry County Community Ministries, which despite its name has no religious mission. She wants to "create a community that values good health," a vision that goes well beyond the cluster of hospital resources perched on the hill above her offices.
"We're out here dying and we're showing up in the emergency room when we're half dead, instead of saying, 'you know what, I live in this community. I want sidewalks,'" she says. "I want ambulance services. I want grocery stores convenient, (so) that all of my neighbors can get there. I'd like to see some form of public transportation," much needed by people without cars in the rugged mountain region.
She advocates a community boot-strap approach in which residents come together as health consumers and pressure the system to meet their specific needs. As an example of how the agency works, Roll cites the area's leading health problem: Type II or adult onset diabetes, largely linked to bad diet and a lack of exercise.
"We'll have a patient who sees the doctor and the doctor says you need to change your diet, and here's a diet and (the doctor) will hand them a sheet of paper, and will tell them to exercise more, to talk or go to the gym, will tell them everything to do," she says.
"And the person will sit there and say 'yes, yes, I'll do that, I'll do that.' They may not do any of that. They may not be able to get to the store. May not know how to prepare the food. They may not want to exercise. And there's no one to encourage them to do that."
So Community Ministries "lay health workers" go into patients' homes once or twice a week, call them on the phone, drive them to the grocery or even organize regular walks with their neighbors — in short , taking an interest in their life.
The health workers are almost always local people. During visits, they evaluate patients' living conditions to see if they qualify for housing and medical care under an array of federal programs, and then complete oral inventories of each client's health history. Afterward they bring the clients into one of the community clinics established in the two counties, and then when necessary refer them to private practitioners who offer limited free consultations in the evenings.
Family nurse-practitioner Beverly May works with Roll at the Little Flower Clinic down by the Kentucky River in one of Hazard's poorer neighborhoods. It and two clinics in Harlan County serve some 2,500 homeless or poorly-housed people. She tells the story of an itinerant Baptist preacher whom she calls "Charlie" to protect his privacy. He had come in for a regular health screening.
"Charlie said, 'Oh no, I don't have diabetes, you don't have to stick my finger.'" A tall, robust, courtly black man — a descendant of the segregated coal camps set up in the 1920s — Charlie was always well dressed, usually wearing a freshly pressed white shirt even with his overalls. He had no health insurance, but he was sure he was perfectly healthy.
May insisted on the test, and found he had a dangerously high blood sugar level. "It didn't take much medication, it didn't take much health care" to fix Charlie's problem, she said, but by doing that "you have greatly reduced someone's risk of getting kidney disease, blindness, heart disease down the line. So by a dramatic drop like that, we have changed his picture entirely for his future. We do that every day."
May says her patients typically come in without having had any care for years — they may not have a job or insurance and can't afford a doctor's fee. Half the population of the two counties falls below the poverty line, and are covered by Medicaid or Medicare, but May says they frequently don't know how to use those government programs for the poor and elderly.
This approach is at the heart of a statewide commission examining health care changes in Kentucky. It's led by Dr. Gilbert Friedell, a crusty 82-year-old who taught at Harvard and the University of Massachusetts Medical School, and ran the University of Kentucky's Markey Cancer Center. He is a doctor's doctor. He thinks, however, that too often doctors are a major problem in creating healthy communities. "Health care," Friedell argues, "has to be a joint enterprise between patients, families and physicians."
Nationally, Friedell believes, the health care debate has to be transformed.
"Currently the issues are framed as insurance or not insurance," he says. "Having insurance gives you financial access to a system, assuming there is a system. It gives you nothing more than that. And getting into the system, if there is one, doesn't tell you anything about the quality of care, the availability of services, the way the patients and families are treated."
Kentucky's fifth congressional district, which includes Harlan and Perry counties, has the lowest life expectancy of any district in America: 72.6 years for men and 76.4 for women. Those numbers would be little changed, Friedell says, by either a government-run system or a requirement that all people have insurance. Substantive change, he says, will only arrive built on a basis of re-ordered health values founded on programs like the ones in Hazard.
(Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy-research organization that isn't affiliated with Kaiser Permanente.)
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