‘We’re out here dying’<\/strong> <\/p>\nGerry 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. It requires building a system that addresses everything from exercise and diet to regular medical screening, and includes services that support good health. <\/p>\n
\u201cWe\u2019re out here dying and we\u2019re showing up in the emergency room when we\u2019re half dead, instead of saying, you know what, I live in this community. I want sidewalks,\u201d she says. \u201cI want ambulance services. I want grocery stores convenient, (so) that all of my neighbors can get there. I\u2019d like to see some form of public transportation,\u201d much needed by people without cars in steep mountain country. <\/p>\n
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\u2019s leading health problem: Type II or adult onset diabetes, largely linked to bad diet and a lack of exercise. <\/p>\n
\u201cWe\u2019ll have a patient who sees the doctor and the doctor says you need to change your diet, and here\u2019s a diet and (the doctor) will hand them a sheet of paper, and will tell them to exercise more, to walk or go to the gym, will tell them everything to do,\u201d she says. \u201cAnd the person will sit there and say yes, yes, I\u2019ll do that, I\u2019ll 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\u2019s no one to encourage them to do that.\u201d <\/p>\n
So Community Ministries \u201clay health workers\u201d go into patients\u2019 homes once or twice a week, call them on the phone, drive them to the grocery or even organize regular walks with their neighbors\u2014in short , taking an \u201cinterest in their life.\u201d <\/p>\n
The health workers are almost always local people. Frequently they are previous clients of community health outreach projects who first became volunteers and then were trained on the job. During visits, they evaluate patients\u2019 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\u2019s 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. <\/p>\n
\n Plenty of government programs,\u00a0little knowledge of how to use\u00a0them
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Family nurse-practitioner Beverly May works with Roll at the Little Flower Clinic down by the Kentucky River in one of Hazard\u2019s 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, which always includes a blood sugar test for diabetes. <\/p>\n\u201cCharlie said, \u2018Oh no, I don\u2019t have diabetes, you don\u2019t have to stick my finger.\u2019\u201d A tall, robust, courtly black man\u2014a descendant of the segregated coal camps set up in the 1920s\u2014Charlie 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. <\/p>\n
May insisted on the test, and found he had a dangerously high blood sugar level. \u201cIt didn\u2019t take much medication, it didn\u2019t take much health care\u201d to fix Charlie\u2019s problem, she said, but by doing that \u201cyou have greatly reduced someone\u2019s 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.\u201d <\/p>\n
May says her patients typically come in without having had any care for years \u2013 they may not have a job or insurance and can\u2019t afford a doctor\u2019s 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\u2019t know how to use those government programs for the poor and elderly. <\/p>\n
\n Health care as a ‘joint enterprise’
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The approach taken by Roll and May is at the heart of a statewide commission examining health care reform in Kentucky. It\u2019s 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\u2019s Markey Cancer Center after spending 12 years directing the National Cancer Institute\u2019s bladder cancer project. He is a doctor\u2019s doctor. But he believes that too often doctors are a major problem in creating healthy communities. \u201cHealth care,\u201d Friedell argues, “has to be a joint enterprise between patients, families and physicians.\u201d <\/p>\nIn 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\u2019re 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\u2014from monitoring to diet to exercise to long-term treatment. A third group is focusing on how well\u2014or poorly\u2014counties are following a new law to enroll every child in a state-mandated health care program. <\/p>\n
The objective is not only to evaluate current health care assets and deficits, but, more importantly, to create \u201ccitizen tools\u201d that can be employed across the state to hold doctors, hospitals and county health boards accountable. <\/p>\n
Nationally, Friedell believes, the health reform debate has to be transformed. <\/p>\n
\u201cCurrently the issues are framed as insurance or not insurance,\u201d he says. \u201cHaving 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\u2019t tell you anything about the quality of care, the availability of services, the way the patients and families are treated.\u201d <\/p>\n
\n Lowest life expectancy
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Kentucky\u2019s 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\u00a0would 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. <\/p>\nAn hour away from Hazard, across the corkscrew roads of Pine Mountain, is Kentucky\u2019s second most famous coal town, Harlan\u2014known for a half century of militant miners\u2019 activism. Coal\u2019s fortunes have declined sharply since the 1960s when more than 60 coal trains a day rumbled alongside the Cumberland River in downtown Harlan. In those days the United Mine Workers union established one of the region\u2019s landmark hospitals to deal with miners\u2019 growing health problems. <\/p>\n
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\u2019t helped much, says Annie Fox, who about a decade ago helped organize a citizens\u2019 committee to address local health problems. <\/p>\n
The group, Harlan Countians for a Healthy Community (HCHC), took the same approach as Gerry Roll\u2019s organization in Perry County\u2014targeting everything from walking trails to clinical care to adolescent drug abuse prevention. <\/p>\n
\u201cAs with so many issues,\u201d Fox says, \u201cwe have this myopic kind of vision of what health is, or what housing is, or what drug abuse is: well, hey, they\u2019re all utilized by the human body, and unless you deal with the whole issue, there\u2019s going to be tons of fallout. That\u2019s why it\u2019s important that you get people in decent housing that they can have a refrigerator, they can have potable water, they can have decent sanitation.\u201d <\/p>\n
\n ‘We’re planted where the need is’<\/strong> <\/p>\nIt\u2019s been a rough road keeping HCHC alive with ever-changing financing mechanisms, but gradually Fox\u2019s group collaborated with community leaders to buy a house in a low-income neighborhood that has become part community center and part clinic. \u201cWe\u2019re planted where the need is,\u201d she says. \u201cThis is a very comfortable place for our clients. They say, \u2018Wow, I\u2019d love to be able to have a home like this.\u2019 Part of our work is to help people realize that dream.\u201d <\/p>\n
Cathy Nance lives in one of 10 houses maintained by HCHC. Perched on Pine Mountain, the highest in the area, the small home has anchored her once troubled life. <\/p>\n
Outreach worker Tracy Grubbs recalls the time they were working for the county and Nance came into work right after open heart surgery, with \u201cbig staples in her chest.\u201d When Grubbs asked why she had come in, Nance said she had no place to live and couldn\u2019t afford to stop working. <\/p>\n
\u201cI had no choice,\u201d Nance says now. \u201cI\u2019m divorced and I didn\u2019t have no other way but to go back to work. And then [when I had] the kidney cancer, it was the same thing. But my health just kept declining and the doctor took me off work.\u201d <\/p>\n
Unable to pay her rent, she was evicted from her apartment and moved in with friends. Then HCHC intervened. The program paid her rent on the house where she now lives until she qualified for Social Security disability, helped her buy new furniture using federal funds and filed requests with pharmaceutical companies for free medications. \u201cIf it hadn\u2019t been for Tracy and her program, it\u2019s no telling what would have happened to me,\u201d Nance says. <\/p>\n
\n Bringing diabetes under control<\/strong> <\/p>\nFox estimates HCHC\u2019s approach has saved Harlan\u2019s 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\u2019 diabetes indicators down to very near the national norms. <\/p>\n
Even so, that kind of success hasn\u2019t ensured that organizations like HCHC and Perry County Community Ministries would find secure funding. HCHC, which won national acclaim for its community-driven approach, was funded as a model research program through the University of Kentucky\u2019s Center for Rural Health. But the flow of dollars ended when the study was finished, which meant that Fox and her colleagues had to scramble to keep the program alive. <\/p>\n
Currently, HCHC\u2019s services result from a collaboration: Fox and Hazard\u2019s Gerry Roll sat down to look at how they could gain access to longer-term state and federal support by joining forces. They creatively applied for money from a variety of sources \u2013 and even enlisted a Rotary Club\u2019s help. <\/p>\n
The programs they run are the sort that former federal rural health advisor Forest Callico says will be essential to any national reform effort that takes actual care seriously. \u201cThe debate about health care transformation has always started with the assumption that it\u2019s all about the money. I think that people in my profession abdicated leadership in health care a long, long time ago to the economists and the attorneys,” he says. <\/p>\n
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. \u201cWe can figure out from people who know each other saying, here\u2019s how we can make these moving parts actually work together in a systemic way.\u201d <\/p>\n
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HAZARD, Ky.\u2014 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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7],"tags":[],"class_list":["post-41095","post","type-post","status-publish","format-standard","hentry","category-news"],"_links":{"self":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/posts\/41095","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/comments?post=41095"}],"version-history":[{"count":0,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/posts\/41095\/revisions"}],"wp:attachment":[{"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/media?parent=41095"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/categories?post=41095"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/mereja.media\/index\/wp-json\/wp\/v2\/tags?post=41095"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}