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
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
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
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
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
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
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
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