January 28, 2010 — Appalachia is known for its natural beauty and its proud, hard-working people, but a shadow that has fallen across the mountains is slowly robbing generations of Appalachians of the long and healthy lives enjoyed by most of the nation.
In response, the Healthy Appalachia Institute – a partnership between the University of Virginia, The University of Virginia's College at Wise, the Southwest Virginia Graduate Medical Education Consortium and the Appalachian Regional Commission – is working to develop strategies to foster a healthier region.
"There is an unequal burden of suffering," said David Cattell-Gordon, co-director of Healthy Appalachia, director of rural network development with U.Va.'s Office of Telemedicine and Cancer Center and a native of the region. Virginia's Appalachian region leads the state in a number of significant health risk factors, he said. "Add the fact that we have high rates of poverty and large numbers of uninsured, and you end up with a high rate of early mortality."
Healthy Appalachia began with the primary goal of changing those factors so Southwest Virginia becomes a national model for solving health problems for rural areas.
Appalachia is a stubborn region. The same hard-working people who carved out a way of life in the rugged region often show an ingrained tendency to resist change when offered by outsiders. The slightest hint of a needed cultural shift can stiffen the spines of the region's most open-minded citizens. Those involved in the Healthy Appalachia Institute realize the region must find a solution that works for the area.
"The only way we can solve the region's health issues is to find a solution born of this region," Cattell-Gordon said. "There are also a tremendous amount of work injuries and high rates of disability with pain medications prescribed and not managed well, leading to staggering rates of fatal unintentional drug overdose, broken families and five times the state rate in the number of children in foster care."
Cattell-Gordon said the basic plan is to use the resources of U.Va.-Wise and all the sectors of the community to develop a viable and innovative strategy.
"The solutions are going to come from the people of the region," he said. "We have more power than we realize by working together. Collaboration is the base of the model."
Healthy Appalachia co-director Marcia Quesenberry said the institute is a strategic partner in bringing both health and health-enabled prosperity to the region. "The solutions need to come from the region. What are the strengths of the University and what are the strengths of the region and how can they work together? This is the first time grass-roots efforts have successfully come together to work collaboratively in Southwest Virginia."
According to Gary Crum, a co-founder of the institute, that collaboration is broad and deep.
"Critical thinkers, scholars, system planners and leaders in government, education, business and health care are crucial to our efforts," Crum said. "Public forums have given our citizens the opportunity to help form the best strategies for improvement. With financial support from the Appalachian Regional Commission and the Virginia Community Healthcare Association, as well as assistance from the Virginia Department of Health, Healthy Appalachia is building the capacity to assist the people of our region."
Having the region's only four-year state liberal arts college involved in finding health care solutions may seem odd at first glance, but Cattell-Gordon said UVa-Wise is a natural fit. The college's strong science and nursing departments are producing effective and powerful health care workers throughout the region, he said. Traditional liberal arts courses, especially those with a strong emphasis on Appalachian studies, combine to create the perfect spot to nurture health care improvements. Add an engaged faculty, and the core of Healthy Appalachia is formed, he said.
The next natural phase is for partners to share research and resources and work on standards for community-based participatory research. Participants have formed Healthy Appalachia Fellows, a group of select students who examine health disparities in the region and participate in clinical experiences. The fellows work with groups such as Remote Area Medical, a mobile clinic that brings health care to rural areas worldwide, and the Health Wagon, a local organization that operates mobile clinics. Cattell-Gordon said the students will travel to Charlottesville to work with U.Va. professors and students in laboratories.
"We are working with incredible resources in our region and within the University, like telemedicine, the Center for Global Health, the Cancer Center, Public Health Sciences, the Office of Economic Development and the schools of Medicine and Nursing to advance our cause," he said. "There is no more reason for people to die of the diseases they are dying of here because of the lack of access to our collective resources and specialty care."
The Healthy Appalachia Institute also serves a vital planning and support function by working closely with the Southwest Virginia Health Authority. The institute and the authority have a strong partnership and a solid commitment from the region's state lawmakers.
Crum, who also serves as the executive director of the Graduate Medical Education Consortium, is coordinating the authority's work from his office at UVa-Wise. He steers the programs toward the goal of improving the health outcomes in Appalachia.
"The potential for Healthy Appalachia is tremendous," Crum said. "There is a mutual commitment to improving the health of the region. We are coming together to see what needs to be done first."
Giving structure to health care planning in the region is vital for real change, Crum said.
"We are not here to change our culture," Crum said. "We are here to understand how to work in the culture and respect the values of the people in Appalachia. There are many reasons people take chances with their health. Our goal is to find the reasons why and help people understand the risks they are taking."
The partners work together to offer direct outreach and clinical programs funded by the Virginia Tobacco Commission and organized through work with U.Va.'s Emily Couric Cancer Center and its Office of Telemedicine.
In December 2008, the U.Va. Health System and Healthy Appalachia, working with the Health Wagon, brought the University's mobile digital mammography van to a sewing factory in rural Dickenson County to offer free screenings and state-supported follow-up care for uninsured patients. The need for the service was apparent, Cattell-Gordon said. The mobile clinic found 10 abnormal mammograms out of the 43 women screened.
"Only 37 percent of women eligible for free breast exams in the region get one," Cattell-Gordon said. "The far Southwest Virginia region has a low incidence of breast cancer, yet women here die from the disease at the same rate as the rest of the Commonwealth. The reason is that women here do not get screened at the same level as the rest of Virginia. Because of that, few cancers are diagnosed at the local, more easily treatable stage."
Appalachian women tend to avoid health care because they worry about the expense to their families. The best way to encourage more participation and more screenings is to reach women through their family relationships and by bringing the resources to them where they live and work, Cattell-Gordon said.
A local woman who received an abnormal screening at the mobile unit and was diagnosed with a local stage cancer brought her two daughters back for a baseline mammogram when the mobile unit returned.
Since 2001, the Remote Area Medical – or RAM – clinic has served some of the area's health needs. In 2008, it provided 7,165 patient encounters served by about 1,000 health volunteers from across the nation, of which 274 were U.Va. volunteers. The value of U.Va. care totaled more than $1 million.
"This is the only health care for a lot of people in Appalachia," Cattell-Gordon said.
Having a healthy workforce is vital to having a vibrant, productive region. Healthy Appalachia Works, a related project, emphasizes the link between a strong economy and the health of a region's workers and focuses primarily on the health of working people. A special emphasis is placed on working women in the region, since many work in service industries that offer little or no health insurance benefits.
"We are creating a model for a regional approach to providing health care with an ultimate goal of moving from treatment to prevention," Quesenberry said. "We want to be a model for rural communities throughout the world."
Healthy Appalachia Works is funded through a $1 million grant from the Virginia Tobacco Indemnification and Community Revitalization Commission given to the U.Va. Emily Couric Cancer Center to promote advanced health care in the region. Healthy Appalachia Works promotes economic development by improving access to health care, improving educational programs and establishing new telemedicine sites. The program also improves distance learning and clinical training for the region's health care workers.
"We've put our homegrown framework for success together and we are moving forward," Cattell-Gordon said. "The strategic blueprint is under way, and we are now at a strategic inflection point that can transform constant sorrow into continuous hope. We are at a moment in time when we will look back and realize that this is when the action we took is the action that changed it all."