Appalachian Health

Culture, Challenges, and Capacity

F. Douglas Scutchfield, Randy Wykoff, F. Douglas Scutchfield, Randy Wykoff

• Publisher: The University Press of Kentucky
• Year: 2022
• ISBN:
  9780813155937
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Appalachian Health explores major challenges and opportunities for promoting the health and well-being of the people of Appalachia, a historically underserved population. It considers health's intersection with social, political, and economic factors to shed light on the trends affecting mortality and morbidity among the region's residents.

Editors F. Douglas Scutchfield and Randy Wykoff have assembled high-profile experts working in academia, public health, and government to offer perspectives on a wide range of topics including health behaviors, environmental justice, and pandemic preparedness. This volume also provides updated data on issues such as opioid abuse, "deaths of despair, " and the social determinants of health. Together, the contributors illuminate the complex health status of the region and offer evidence-based programs for addressing the health problems that have been identified.

1

Introduction

F. DOUGLAS SCUTCHFIELD AND RANDY WYKOFF

I shall not leave these prisoning hills

Though they topple their barren heads to level earth

And the forests slide uprooted out of the sky.

Though the waters of Troublesome, of Trace Fork,

Of Sand Lick rise in a single body to glean the valleys,

To drown lush pennyroyal, to unravel rail fences;

Though the sun-ball breaks the ridges into dust

And burns its strength into the blistered rock

I cannot leave. I cannot go away.

Being of these hills, being one with the fox

Stealing into the shadows, one with the new-born foal,

The lumbering ox drawing green beech logs to mill,

One with the destined feet of man climbing and descending,

And one with death rising to bloom again, I cannot go.

Being of these hills I cannot pass beyond.

James Still, “Heritage”

Why Appalachia?

This book is about the health and well-being of the people of Appalachia and the many social, economic, geographic, and medical factors that have long distinguished the region from the rest of the United States. Why study the people of Appalachia? In many ways, this is both a simple and a complex question. It is simple because the people of Appalachia, and the residents of other rural and isolated parts of the country, are currently in the national consciousness. Appalachia is, in many ways, an economic and political bellwether for the United States. Periodically, the national political discourse prompts the media to refocus their attention on the problems and issues of the people of Appalachia, after these issues have been out of the public eye for some time. One of the best examples is the iconic picture of Lyndon Johnson “hunkered down” (as the mountain folks say) to talk about jobs on the porch of an unemployed mill worker in Martin County, Kentucky (figure 1.1). Johnson used this photo opportunity as a prelude to announcing his War on Poverty in 1964. Others have used Appalachia either to highlight a presidential initiative or to campaign for the office. Both John F. Kennedy and Robert Kennedy visited the mountains while running for the presidency, as did Bill Clinton.

Figure 1.1. President Lyndon B. Johnson in Appalachia. (Source: Lyndon B. Johnson Library Archive; photograph by Cecil Stoughton)

During these times of national attention, the well-being of the people of Appalachia becomes part of the national dialogue, and they are viewed sympathetically as an example of the challenges facing the country. However, the 2016 presidential election may have changed this sympathetic view of the Appalachian people. In that election, the majority of the region’s voters, despite their traditional affiliation with the Democratic Party, cast their ballots for the Republican candidate, Donald Trump. Indeed, the people of Appalachia (and voters in other economically depressed regions) were thought to be largely responsible for Trump’s election. They have since been cast as his base: disaffected, disadvantaged, discouraged, and, in an economic sense, displaced.

This view is not entirely correct: Appalachia and other rural areas were not the sole source of President Trump’s victory. In addition to carrying all but two of the states containing parts of Appalachia (the exceptions being New York and Virginia, where the Appalachian counties are a very small minority), Trump won most of the rest of the country, geographically speaking. Nevertheless, some people view Appalachians (and their counterparts in other rural areas) as the force that propelled Trump to the White House. This perceived political importance of Appalachia has once again motivated the rest of America—and especially the media—to reexamine the region in an attempt to understand the political dynamics there, as evidenced by the New Yorker’s “In the Heart of Trump Country” and PBS’s “Once a Clinton Stronghold, Appalachia Now Trump Country.” Through these explorations, journalists have attempted to outline the myriad factors that caused the people of Appalachia to move away from their traditional party affiliation and seemingly to repudiate many of the social programs designed to help them.¹

Thus, the simple answer to the question why study the people of Appalachia is that Appalachians are, once again, squarely in the public eye. The more complex answer—and the more important one—is that there are real and significant challenges (economic, social, medical, and others) that impact the health and well-being of the region’s people. These factors are not, of course, unique to Appalachia; thus, understanding (and ultimately addressing) them could improve the welfare of Americans in all parts of the country, especially those who have not benefited from the nation’s economic growth. For example, the decline of the coal industry, which has increased unemployment in major West Virginia, eastern Kentucky, and eastern Tennessee communities, is not fundamentally dissimilar to the decline of manufacturing in the Rust Belt or the decline of textiles in the Southeast. Certainly, over the coming century, many other sectors will evolve and change, placing entire regions on a downward economic trajectory. This type of decline is associated with many other challenges that will be marked, in region after region, by worsening health, social, and economic cycles.

Yet we can influence these trends if we systematically evaluate and understand similar processes in Appalachia. Doing this work requires clear acknowledgment of the fact that Appalachia is not monolithic, although the counties within the region do share marked health-related inequalities. In speaking of “the persistent poverty and human suffering in the mountains,” Eller paints a picture of the region’s complex landscape. He notes that “the decline of coal mining jobs due largely to changing markets; the absence of employment alternatives; the rise of opiate addiction; higher rates of depression, heart disease, and cancer; growing dependence upon Medicaid and SSI [supplemental security income]; and insufficient tax revenues for education and other local services continues to set Appalachia apart as one of the most distressed parts of rural America more than five decades after Lyndon Johnson declared his War on Poverty.”²

Why Appalachian Health?

The first step in studying the health and well-being of the people of Appalachia is to analyze the interrelated cycles of social, economic, medical, and other conditions that have produced the region’s current health status. The second step is to develop strategies that can interrupt these cycles—in Appalachia and elsewhere. Understanding the interrelationship among these factors will help guide the nation’s response to future health challenges, wherever they occur.

Many Americans presume that their health is among the best in the world. However, although the United States spends substantially more on health and health care than any other developed nation, this investment has not translated into improved health status. In fact, the United States is one of the least healthy of the world’s advanced economies. As 2018 data from the Organisation for Economic Co-operation and Development (OECD) show, despite the United States’ outsized spending on health care, Americans’ overall life expectancy trails that of the majority of economically developed countries (figure 1.2).³

Figure 1.2. Life expectancy versus health care expenditures (percentage of gross domestic product) among OECD countries, 2018.

According to the Institute of Medicine (IOM), which compared US health indicators to those in sixteen other “peer” countries in 2013, there are nine areas in which the United States lags behind:

■ Adverse birth outcomes: The United States fares worse than many countries in infant mortality and low-birth-weight babies.

■ Injuries and homicides: The United States outpaces its peers in vehicular and non-traffic-related injuries, as well as violent deaths.

■ Adolescent pregnancy and sexually transmitted disease: Among developed nations, the United States has the highest rate of pregnant teenagers and sexually transmitted disease.

■ HIV and AIDS: The United States is second among its peers in the prevalence of HIV infection, and it is number one in the incidence of AIDS.

■ Drug-related mortality: More years of life are lost in the United States to alcohol and other drugs, even when drunk-driving deaths are excluded, than in any other peer nation.

■ Obesity and diabetes: The United States is the most obese country among its peers, and it leads all others in the prevalence of diabetes among those older than twenty.

■ Heart disease: The United States is second among developed nations in heart disease mortality prior to age fifty; Americans older than fifty are more likely to have cardiovascular disease and die of it than individuals in peer nations.

■ Chronic lung disease: The United States is worse than all European countries in the prevalence of and mortality from lung disease.

■ Disability: The United States has a higher rate of arthritis and activity limitation than European countries and Japan.

Though many of these health disparities exist across the economic spectrum, the vast majority are worse in Appalachia.⁴

The IOM report describes potential contributors to US health disparities, including a fragmented health care delivery system that is driven by volume, not value, and in which consumers must structure their own set of providers to receive the breadth of care required. It also cites the health habits and behaviors of Americans, who consume more calories, abuse more prescription drugs, use seatbelts less frequently, have more drunk-driving accidents, have easier access to firearms, and are more likely to become sexually active at an earlier age and have more sexual partners than individuals in other nations. Additionally, Americans have higher poverty rates (particularly among children) and a higher rate of income inequality, and the US government spends fewer funds on “safety net” programs. This last point is particularly important, as research has demonstrated that social spending in developed nations is inversely related to health outcomes. In other words, countries that spend money on education, food support, housing, transportation, employment, and social support enjoy a better health status. Finally, there is substantial evidence that the built environment can positively influence health status. For instance, many other developed nations are providing incentives for people to bicycle to work, thus encouraging physical activity while simultaneously decreasing mortality and morbidity associated with auto accidents and environmental pollution.⁵

As highlighted in this book, many of the same factors that cause heal...