Tuesday, September 07, 1999
Death rates elevated in Appalachian areas
BY TIM BONFIELD
The Cincinnati Enquirer
Heart disease. Lung disease. Liver disease. Name the cause of death, and chances are, people are dying from it more often in southern Ohio's Appalachian counties than in the rest of the state.
A new report on the 15 leading causes of death says the cluster of six counties at the southern tip of Ohio — Adams, Pike, Scioto, Vinton, Jackson and Lawrence — rank among 11 counties with the state's highest death rates.
The mortality mapping study was produced by the Health Planning & Resource Development Association of the Central Ohio River Valley (CORVA).
Many factors are to blame. Poverty. Lack of health insurance. Lack of health services. Maybe even Appalachian culture.
“It's a combination of all those factors,” said Susan Isaac, a health researcher at Ohio Uni versity in Athens and chairwoman of a state Appalachian Task Force. “We're talking about some of the deepest poverty in the state.”
Regardless of the cause, the high death rates show up in CORVA's color-coded maps as a swath of red and blue ripping through southern Ohio.
Pike County's death rate — the highest in Ohio — was 47 percent higher than the county with the lowest death rate — Delaware County, a suburban county north of Columbus.
In Greater Cincinnati, the counties at the western edge of Appalachian country — Adams, Brown and Clermont — all have higher overall death rates than Hamilton County.
Of the eight local counties in the CORVA study, Hamilton County had the highest rates in four of the 15 leading causes of death: AIDS, infant deaths, homicides, and septicemia.
Adams County had the highest overall death rate plus the highest rates in five categories: heart disease, suicide, accidents, atherosclerosis, and liver disease.
Clermont County topped the list for cancer and lung disease. Clinton County had the highest rates for pneumonia, diabetes and stroke.
Butler County had the highest rates of kidney disease.
None of this comes as any surprise to Gary Roberts, director of Pike County's Family Health Center in Waverly. Not only has Mr. Roberts seen plenty of suffering people coming through the clinic, he has seen Appalachia's unhealthy trends strike his own family.
“My father died of a heart attack when he was 45 years old. My brother had open heart surgery for a five-way bypass at the age of 53,” Mr. Roberts said.
His father was a heavy smoker with bad eating habits. So was his brother before his surgery.
So now, at age 51, Mr. Roberts works to avoid the same fate. He's a regular jogger and a nonsmoker. He gets a physical every year, with a close eye for signs of heart disease. So far, so good, he says.
“I try to live a healthy lifestyle. But there's a resistance here toward seeking out preventive health care. People won't change their diets or start exercising,” Mr. Roberts said.
Many say the high death rates in Appalachian counties can be traced to several well-known factors: high unemployment; low income; lack of health insurance; lack of health services.
In June, the unemployment rate for Adams County was 7.8 percent — three times higher than the 2.6 percent unemployment rate in Warren County, which has the lowest death rate in Southwest Ohio. Go to Morgan County, another heavily Appalachian county, and you find unemployment rates peaking at 14 percent.
Lack of health insurance marches hand-in-hand with joblessness. An estimated 28 percent of people in Adams County have no health insurance, compared with state averages around 11 percent.
Insured or not, southeast Ohio never has been able to attract enough doctors to meet the need, especially when compared with more urban counties. The doctors who do work in Appalachia often are assigned to work there in return for grants that helped pay for their training. Once their commitments are up, many leave.
But some say the cycles of poverty and poor health have become so deeply entrenched that they have become part of the Appalachian culture.
“There's a sort of fatalism in Appalachian people,” Mr. Roberts said. “They say, "We're all going to die anyway. Something's going to get you. So why bother?'”
Smoking rates are high. Dietary habits are poor. Obesity is common. And lots of people won't go to the doctors that do practice in the area.
High suicide rates reflect economic and personal despair combined with thin mental health services. High death rates from accidents partly reflect the occupational risks of farming. More often, however, the deaths reflect car crashes from drunken driving along curvy, hilly country roads.
Be it lack of health insurance or personal choice, many people in rural counties delay seeking treatment until they are so sick they need hospital care, Ms. Isaac said.
High blood pressure and high cholesterol go undiagnosed until the heart attack or stroke hits. Diabetes goes undetected until a kidney fails.
Then, a few years after the funerals, the deaths show up as statistics that paint entire counties red.
“It's such beautiful country down there. It's just sad to see such need,” said Jim Sandmann, CORVA president.
Joe Doodan, executive director of the Ohio Primary Care Association, said rural health care problems have been underaddressed for too long.
“None of these problems are new. The question is, what are we going to do about them?” Mr. Doodan said. “We need to get out there, pick some communities and see if we can make some change.”
In Kentucky, another state with deep rural health problems, workers with the University of Kentucky's Coronary Valley Proj ect have launched an experiment in Clay County to battle high rates of heart disease. Health workers are going door to door to do screening tests, looking for those people who haven't been to doctors in years.
Early screening results have been disturbing. More than 55 percent of those tested had high cholesterol and 52 percent had high blood pressure. About 22 percent were glucose intolerant — a warning sign of diabetes.
Nothing so intense has been attempted in Ohio, which also is considered part of the 12-state Coronary Valley. In many places, including Adams and Brown counties, cuts in federal grants have forced rural health clinics to cut their education and outreach efforts.
The Southern Ohio Health Services Network had a full-time health educator — four years ago. It also had a coronary disease program that visited local employers to teach workers about healthy nutrition. But nobody picked up the program after the three-year grant ran out.
“Health education takes money,” said Dr. Blair Chick, medical director. “We're talking about changing lifestyles, not just of individual patients, but of a whole culture.”
But some signs of renewed effort are emerging, Ms. Isaac said.
Ohio University recently launched a Center for Rural and Appalachian Health Studies. The area also has been helped by recent state efforts to expand health coverage for uninsured children.
For the western parts of the area, the Health Foundation of Greater Cincinnati also has been a new source of grant money. The charity — formed by the $250 million sale of ChoiceCare to Humana Inc. — already has awarded some planning grants to outlying counties. It remains interested in funding more projects focusing on mental health, substance abuse and school-based health programs.
Perhaps the biggest infusion of money in years is yet to come. Many hope the multibillion-dollar tobacco settlement will dramatically expand public health efforts in Appalachian Ohio — an area plagued by high smoking rates that is also home to many tobacco farmers who will need assistance if the market declines.
Few are under any illusions that Appalachian poverty will be swiftly reversed, or that doctors will suddenly line up to work in the backcountry. But Ms. Isaac sees opportunity.
“For years, I've felt like I was one of the only people out here going, hmmmm,” Ms. Isaac said. “But now there's some attention and that's a positive first step.”
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