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Aug 13, 2013

A Lesson From Hazard

Wayne Myers, MD, Look What's Coming columnistby Wayne Myers

Hazard is the seat of Perry County, Kentucky, one county west of the Eastern Continental Divide, which marks the boundary with Virginia. In a recent study Perry County had the shortest life expectancy for women, and the third shortest for men, of all the counties in the United States. The study was done by the Institute of Health Metrics and Evaluation (IHME) and published in the National Journal (no longer available online).

My wife JoAnn and I lived and worked in Perry County from 1990 to 1998 and have stayed in touch since then.

A look at data from the Foundation for a Healthy Kentucky (no longer available online) shows that the leading cause of death, and the one that is distinctively high in east Kentucky, is cardiovascular: mostly heart attacks and heart failure.

Perry County's strikingly poor life expectancy numbers call into question some generally accepted ideas about factors determining the life spans of populations. It seems to me Perry County is a caricature of the rest of the country.

Perry County has an abundance of medical care. Hazard is a town of about 5,000 in a county of 29,300. It has a hospital of 306 beds being expanded to 360 beds, a family practice residency, open heart surgery, a cancer center with various treatment modalities and patient navigators, an obesity treatment center and all the major specialties except neurosurgery. I've argued that it's over-doctored. The mortality data suggests I'm wrong.

Until recently Kentucky had a pretty good Medicaid program. Through much of the 1980s and 1990s, its Senate Health and Welfare Committee was chaired by Dr. Benny Bailey, a masterful legislator, clinic administrator and champion of poor mountain people and their health care.

Coal mining is a dangerous job. There are lots of federal safety regulations, but the miners say the rules are rarely enforced. When we lived there, though, only a couple hundred people were working in the mines, and very few of these were women, so mine related diseases seem unlikely to be significant mortality factors for them.

There are no immigrants and very few minority people in the coalfields around Perry County. A million people have moved out of Central Appalachia since the 1960s looking for opportunity, but very few people have moved in.

Rates of smoking, obesity and physical inactivity are quite high.

Marijuana growing is of some significance, but probably not compared to some neighboring counties. Prescription drug abuse is very serious.

In 2011 the state of Kentucky turned over its Medicaid program to three private corporations. That's been a troubled process, but it has had no effect on the data period of this study.

The community has been able to recruit international medical graduates through the Appalachian Regional Commission for about 40 years. It has a disproportionate number of referral doctors compared to primary care types, but it's not medically underserved.

Perry County is poor, and has been one of the Appalachian Regional Commission's Distressed Counties for a long time, but it is by no means the poorest county in Kentucky, as measured by family or per capita income. Median figures, though, obscure the fact that there are very rich and also very poor people in Perry County. Palatial homes of doctors, coal entrepreneurs, bank managers and truck fleet owners are notable.

When we moved just across the county line into Breathett County, our nearest neighbors were a young couple in an old trailer. He was legally blind, in his late teens, and earned some income taking parts from junk cars parked along the shoulder of the road. She was 15 or 16, with two kids. They had no running water and not so much as an outhouse for a toilet.

The special thing about Perry and the adjoining counties was that all the cards were never in sight. I used to pick up an old hitchhiker who was rather proud of being a designated mine owner. The real owner was a local politician and businessman who had been barred from the mining industry by the feds, and had therefore assigned token ownership of his mines to people like my passenger. Such arrangements were pretty well known.

So we have a county with very high death rates, abundant high quality health care, particularly referral care, immense poverty side by side with great wealth, a perception that some are above law enforcement, and few disease prevention programs that I know of.

More and more data from here and abroad shows that it's not so much the poverty, but the perceived disparity in situations that makes people sick. The distinctive thing about eastern Kentucky may not be the poverty but the disparity between rich and poor, and the awareness that the game is not being played fairly, that shortens people's lives. Perry County suggests that you can't fix the health effects of a bad life situation with more medical care.

Over the last 30 years the United States has come to look more and more like Perry County with the spread between rich and poor increasing, and a perception that large financial interests get more favorable treatment than the poor and unemployed.

Is that why the United States has fallen to 51st place in life expectancy among the world's nations in spite of our world champion medical spending?

Dr. Myers thanks Bill Bishop of the Daily Yonder, who has been working on the life expectancy issue from a rural perspective, for bringing the IHME study to his attention.

Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000, and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.

Back to: Summer 2013 Issue