Community Healthcare in Appalachia

Clemens 1

Anna Clemens

IDIS 400 Section 02

Dr. Martin

14 October 2015

Community Healthcare in Appalachia

Currently, the Appalachian region is facing a health crisis. In the United States, we have only recently adopted universal healthcare, although at a tragically non-inclusive rate; there are 30 states that have voted to pass Medicaid expansion, 1 that has yet to vote, and 19 that have voted against the proposal. Virginia is one of the 19 that havedecided against passing the expansion; the outcome of this vote will deny some of the most marginalized Virginians access to Medicaid. Our state has sided with the majority of southern states in the Appalachian region to forego the federally funded expansion, but provides no alternative. While there is still affordable healthcare available, it is well known that Virginia has some of the strictest requirements in the country—guidelines that often bar patients from receiving affordable care and place the responsibility of the ACA on the federal government, which significantly lessens the services available and the program’s inclusiveness. The hardest hit by this refusal to expand are the poor, those whoneed the expansion most. These people are usually living in the most at-risk communities, and states, as they do not have the resources to afford health insurance; an issue made clear by their geographic locations. It is well known that the Appalachian region fares worse than surrounding and comparative areas with “reports [stating] that per capita personal income, real wages, salaries per job, and market income are significantly lower in all communities in Appalachian areas, compared to the respective state’s averages,” this includes Virginia (McGarvey, 2011, p. 349). Furthermore, McGarvey argues that “Central Appalachia, where most counties in Virginia are located, has the worst economic indicators of all the Appalachian regions,” despite this, the state has not offered a viable solution to health issues plaguing the region (McGarvey, 2011, p. 349). In the case of healthcare solutions for the Appalachian region, the discourse is dominated by an overwhelming significance placed on personal “rights [that] have been elevated to a status of supremacy over collective interests,” thus making it nearly impossible for any type of community based health care system to flourish (Blank, 2012, p. 419).

While all the articles agree that the Appalachian region, and areas like it, are poverty-stricken and overall home to poorer health as “residents living in communities in Appalachian counties in VA are not receiving adequate health care,” the authors debate the causes of this issue, the manifestations of this relationship, and the possible solutions (McGarvey, 2011, p. 248). Short, for instance, argues thatthe region’s “weak economy […] generally [results in] poorer preconception health” for women, and that the poverty here “is often related to increased rates of uninsured citizens (Short, 2012, p. 246).” By making this connection, Short makes the point that uninsured citizens are both poor in economic means as well as health. Important to consider when contemplating the results of McGarvey’s study on illness, which claimed that it “did not find significant differences in the number of chronic diseases per person by place of residence,” although the researchers here claim that this is because “community residents […] wait longer to seek health care […] due to a cultural tendency to be ‘self-reliant’, and perhaps ‘fatalistic’ (McGarvey, 2011, p. 354).” When comparing these two theories, one could make the claim that the supposed nature of Appalachian residents may actually be a result of their uninsured status. Similarly, Harris’ study on maternal smoking rates cites difficulty “due to […] cultural barriers (Harris, 2015, p. 240),” although the researchers also recognize that if the program were implemented on a larger scale in the region that “telephone service […] may need to be provided,” thus pointing to economic barriers (Harris 2015, p. 241). For the researchers to cite examples of culture as potential reasons for the failure of programs appears short sighted as they often fail to recognize the importance that the economic state of participants bears on the result.

These at-risk Appalachian dwellers are described as possessing “strong family support systems and social ties, religious affiliation, pride in self and family, [and] independent self-reliance (McGarvey, 2011).” Unfortunately, McGarvey also describes these people as “distrust[ing] of formalized medical systems,” not a promising outlook for those trying to drum up support for expanded Medicaid. However, this does leave room for systems similar to those presented by Harris—home-based healthcare. In this type of healthcare, “combining a brief, behaviorally intensive and incentivized program with a [phone based] counseling program […] may be ideal” for combatting issues of low adherence (Harris, 2015, p. 244). By bringing healthcare to areas heavily distrusting of formal healthcare, we “can eliminate some of the barriers […] typically experienced by lower income [people] residing in underserved areas,” as shown in Vyas’ mobile mammogram study (Vyas, 2013, p. 705). We see a need, but also a pushback by those people who are wary, independent, and prideful, those who would not necessarily be at ease with this idea of ‘hand-out,’ community health care.

I believe this pushback is what hinders the ability for the region to coalesce and tackle its problems through the community and local government. There is this disconnect between what those most desperate for health care are asking for and what is being provided. There are currently nine southern states that have decided not to expand Medicaid, which means the most formalized, and arguably the largest, of these healthcare providers will not be present in significant tracts of Appalachia. This means that these states are both in desperate need, but are also in denial caught between people who reject big government and a state that utilizes these perceptions to slash funding. These areas continue to suffer as they are allowing for an internal paradox—need and un-want. It is at this intersection that we see these misled notions for what they are—the direct result of disparities found in communities in “rural locations [that are home to people] less likely to seek medical care or receive specialized treatments (McGarvey, 2011).”

Vyas’ research, however, offers solutions to this with findings on mobile mammography, which show that there is a substantive argument for non-traditional healthcare practices in the Appalachian region. Mainly, the program tackled “financial and insurance constraints, as well as access to medical care,” access that ultimately allowed these women agency through the “offering [of] low-cost or free-of-cost services (Vyas, 2013, p. 705-6).” An additional non-traditional method presented by the authors was the implementation of story theory in Appalachian healthcare as a means to break down cultural barriers and open a dialogue of care between the nurse and patient. Gobble presents the story of a woman named Molly to describe the context of story theory before ultimately asserting that “listening attentively to what matters most in dialogue enables the caring/healing process that is essential to promoting health” to take place in an opportune way (Gobble, 2009, p. 104). To recognize the religious ties prevalent in the Appalachian region could lead to a change from people who do “not believe in seeking the services of health care providers” and instead relying on religious means to people who are able to find a healthy balance between modern medicine and religion (Gobble, 2009, p. 96). For instance, while Molly had to be “taken to a neighboring state for skin grafts” after being badly burned, she also continued “pray[ing] for her recovery (Gobble, 2009, p. 96).” Although this type of care practice occurs between care provider and patient at a personal level, it is a theory that speaks to the broader needs of the Appalachian region. The people here require healthcare providers and systems that will value the culture of the community and work with them on a local, personal level—sweeping reforms have not worked well, and the national government has not provided the services necessary, even with the national passing of the ACA. True help in the Appalachian region would take the form of community based, local government led initiatives, otherwise the region will not respond positively as it has to smaller scale programs—the mobile mammography unit, over-the-phone tobacco counseling, and story theory in nurse-patient relationships.

I would hope that we can find a better, more equal ground to operate on considering there are, quite literally, lives at risk. I do know, however, that we cannot get anywhere in the discussion to help people when we have a healthcare system that is currently not willing to tackle Appalachian healthcare because of “cultural, geographical and other barriers” that result challenging “prevention of mortality and disease (McGarvey, 2011, p. 355).” This rhetoric places blame on the Appalachian people,as well as full responsibility for their situation while advising individual “proactive efforts”, rather than promoting community health. This perpetuates the uninsured and uncared for nature of Appalachia; what we need is to try “connecting […] to create ease” within communities and the region as a whole (Gobble, 2009, p. 101). Without this connection, healthcare in Appalachia will continue to allow “the individual [to] always trump the community (Blank, 2012, p. 423)” rather than create local systems that “benefit the wider community (Blank, 2012, p. 419).” These “rural and hard-to-reach populations (Vyas, 2013, p. 699)” do not benefit from national programs as well as they do community programs, as evidence has shown despite years of “significant improvements [in large-scale aid] reported in many mountainous regions (McGarvey, 2011, p. 355).” If the people of Appalachia were to utilize the sense of community so ingrained in their culture, they could achieve massive amounts of community power, which would renew the community in body and spirit. Keeping the solutions at the local scale allows the region to maintain control over their health; to achieve this, the people of Appalachia must gain agency as a community rather than remain merely subjects in pilot programs. Appalachia needs community solutions that will break the marginalized mold of poverty that is so often masked as cultural mountains too great to climb by state governments—local government is the key to proper healthcare for these people.

References

Blank, R. (2012). Transformation of the US healthcare system: why is change so difficult?Current Sociology, 60(4), 415-527.doi: 10.1177/0011392112438327

Gobble, C.D. (2009). The value of story theory in providing culturally sensitive and advanced practice nursing in rural Appalachia.Online Journal of Rural Nursing & Health Care, 9(1), 94-105. Retrieved October 10, 2015 (

Harris, M.; Reynolds, B. (2015).A pilot study of home-based smoking cessation programs for rural, Appalachian, pregnant smokers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(2), 236-246.doi: 10.1111/1552-6909.12547

McGarvey, E.L.; Leon-Verdin, M.; Killos, L.F.; Guterbock, T.; Cohn, W.F. (2011).Health disparities between Appalachian and non-Appalachian counties in Virginia USA.Springer Journal of Community Health, 36(3), 348-356.doi: 10.1007/s10900-010-9315-9

Short, V.L.; Oza-Frank, R.; Conrey, E.J. (2012). Preconception health indicators: A comparison between non-Appalachian and Appalachian women. Maternal and Child Health Journal, 16, 238-249. doi: 10.1007/s10995-012-1129-1

Vyas, A.; Madhavan, S.; Kelly, K.; Metzger, A.; Schreiman, J.; Remick, S. (2013). Do Appalachian women attending a mobile mammography program differ from those visiting a stationary mammography facility? Journal of Community Health, 38: 698-707. doi: 10.1007/s10900-013-9667-z