From a strip-mined bluff at the edge of this famous mountain town 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 for 40 years was a coal boomtown, rests at the center of the worst life expectancy in America, according to a 2008 report by the American Human Development Project. Diabetes, asthma, lung cancer and emphysema, heart disease and life-long obesity are all problems encountered in the waiting rooms of these facilities.
Very little is likely to change under any of the current health overhaul initiatives, say some experts like Dr. Forest Callico, former director of the Appalachian Regional Hospitals and a rural health advisor to both the Clinton and second Bush administrations. "It's not all about the money," says Callico. "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 like Hazard that could prove instructive to rebuilding healthy communities across the nation, both rural and urban.
'We're Out Here Dying'
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. She says it requires building a system that addresses everything from exercise and diet to regular medical screening, and includes services that support good health.
"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 steep mountain country.
She advocates a community boot-strap approach in which residents come together as health consumers and pressure the system to meet their specific needs. Type II or adult onset diabetes, largely linked to bad diet and a lack of exercise, is the area's leading health problem, says Roll.
"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. Afterwards 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.
Health Care As A 'Joint Enterprise'
The approach taken by Roll and others is at the heart of a statewide commission examining health care 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 after spending 12 years directing the National Cancer Institute's bladder cancer project. He is a doctor's doctor. But he believes 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."
In operation for about a year, the Friedell Committee, as it is known, has organized a series of working groups aimed at generating citizen activism on local health issues. One group is targeting a half dozen counties where citizens will be encouraged to challenge local boards of health on what they're doing to improve local health markers. Another is targeting three counties where diabetes is prevalent, urging local leaders to press their health services to develop a coherent plan of coordinated care--from monitoring to diet to exercise to long-term treatment. A third group is focusing on how well--or poorly--counties are following a new law to enroll every child in a state-mandated health care program.
Nationally, Friedell believes, the health overhaul 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. Many factors contribute to those numbers and they 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 one Gerry Roll and her colleagues have tried to build in Hazard.
Saving Local Hospitals Money
An hour away from Hazard, across the corkscrew roads of Pine Mountain, is Kentucky's second most famous coal town, Harlan. Coal's fortunes have declined sharply since the 1960s, when the powerful United Mine Workers union established one of the region's landmark hospitals to deal with miners' growing health problems.
The UMW hospitals were long ago converted into non-profit hospitals known as the Appalachian Regional Hospital system. Today, the biggest health problem is diabetes and its associated cardio-vascular problems. As in Perry County, half the population qualifies for Medicare or Medicaid. But simply qualifying for public insurance hasn't helped much, says Annie Fox, who about a decade ago helped organize a citizens' committee to address local health problems.
The group, Harlan Countians for a Healthy Community (HCHC), took the same approach as Gerry Roll's organization in Perry County--targeting everything from walking trails to clinical care to adolescent drug abuse prevention.
"As with so many issues," Fox says, "we have this myopic kind of vision of what health is, or what housing is, or what drug abuse is: well, hey, they're all utilized by the human body, and unless you deal with the whole issue, there's going to be tons of fallout. That's why it's important that you get people in decent housing that they can have a refrigerator, they can have potable water, they can have decent sanitation."
Fox estimates HCHC's approach has saved Harlan's Appalachian Regional Hospital at least a half a million dollars a year in non-compensated emergency room visits and other care. Though no countywide health statistics are available, both the Hazard and Harlan clinics also report that they have brought their 2,500 patients' diabetes indicators down to very near the national norms.
The programs Fox and Hazard's Gerry Roll run are the sort that former federal rural health advisor Forest Callico says will be essential to any national overhaul effort that takes actual care seriously. Financing alone will solve few of the problems of rural or urban health care, Callico says. He argues that the community initiatives stitched together like those in Harlan and Perry Counties provide solid bottom-up models for a profound shift in the overall health policy debate. "We can figure out from people who know each other saying, here's how we can make these moving parts actually work together in a systemic way."
This story was produced through collaboration between NPR and Kaiser Health News (KHN), an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health-care policy research organization. The Kaiser Family Foundation is not affiliated with Kaiser Permanente.
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