Appalachian Health and Well-Being

2. Health and the Physical Environment

47 2 Health and the Physical Environment Michael S. Hendryx Appalachia is known for its mountains and rivers, its forests, hills, and streams. It is known for its music and its heritage. It also includes large cities (Birmingham, Chattanooga, Pittsburgh), major industries, and, perhaps most centrally, coal. The complex interplay of historical, geographic, geologic, social, economic, and anthropogenic forces affects the health of the Appalachian population in profound ways. This chapter explores these influences, documents their impacts, and recommends policies and programs to restore the Appalachian physical environment for the promotion of public health. Because Appalachia suffers from major health disparities relative to the nation,1–3 and because Appalachia is interconnected with citizens in the rest of the nation, such health promotion will benefit not only the region but also the entire country. The Environmental Riskscape Appalachia is the mountainous area in the eastern United States extending from southern New York to northeastern Mississippi. The region designated Appalachia currently includes 420 counties, although the data used in this chapter are based on the 410 counties so designated in 2007.4 The topography of the region consists of three parallel belts running northeast to southwest; they are (from east to west) the Blue Ridge, the Ridge and Valley (which is actually hilly in most areas but has served as the major transit route within the region), and the Appalachian Plateau.5 Throughout the region, east-west passages are rare and were difficult to navigate before modern transportation routes were constructed, especially in the South. Farmlands and valleys are small, offering limited opportunities for 48 Michael S. Hendryx agriculture and the development of urban centers. Much of the area is covered by second-growth broadleaf forest that constitutes one of the most diverse temperate ecosystems in the world. The Appalachian region is also divided into Northern, Central, and Southern subregions.6 Historically, the Northern subregion has fared the best economically, but more recently it has been overtaken by economic growth in the Southern subregion. Poverty levels have remained persistently high in the Central subregion. As coal mining became more mechanized over time, employment in that industry began to fall, and the coal mining areas of eastern Kentucky and southern West Virginia have experienced disadvantageous socioeconomic conditions that persist to the present time. Although this chapter focuses on the Appalachian physical environment and its relation to the population’s health, poor health outcomes result from the combined effects of the total environmental “riskscape”: genetic, social, psychological, behavioral, and physical environmental contributions . Models of the environmental riskscape conceptualize health as the consequence of both chemical and nonchemical stressors that impair the body’s capacity to regulate, repair, and improve physical function.7 The combined and cumulative burden the body experiences from this set of contributions is termed“allostatic load.”8 The more the body is biologically challenged by combined forces such as smoking, environmental toxicants, chronic stress, and poor diet, the more difficult it becomes to maintain a healthy system. The body’s defenses and its regulatory capacity to respond to biological challenge eventually break down. Allostatic burdens begin in childhood, when poverty and chronic stress increase subsequent risks for physical illness, emotional distress, and risky behaviors, including substance abuse and overeating.9–11 The concept of allostatic load indicates that in many cases, illness does not result simply from exposure to a particular environmental agent; it requires exposure to that agent in the face of additional risk factors, be they genetic, psychological, behavioral, or social in nature. Likewise, positive health outcomes may result even in the presence of environmental exposure when other strengths or resiliencies are present in the riskscape. In Appalachia, the physical environment cannot be evaluated in isolation from these other impacts; rather, their interactive, synergistic effects must be considered jointly. Health and the Physical Environment 49 People in Appalachia experience higher riskscape exposures across a spectrum of behavioral, socioeconomic, and environmental threats.1, 3 For example, smoking and obesity rates are higher in Appalachia compared with national averages (table 2.1). Many Appalachians also experience chronic socioeconomic disadvantages: lower income levels, higher poverty rates, higher unemployment rates, and lower rates of educational attainment (table 2.1). Socioeconomic disadvantage is one of the most powerful predictors of poor health outcomes in a population.12–14 For example, Woolf and colleagues13 demonstrated that a college education is eight times more powerful than combined advances in...