Appalachian Health and Well-Being

Introduction

1 Introduction The story of Appalachian health and health care is one of complexity and paradox. At various times and in different places throughout the region’s history, health care has been the province of herbalists, granny women, missionaries, company doctors, nurse practitioners, labor unions, church groups, community-based organizations, private practitioners, and state and federal governments. At various times and places, the region has experienced a shortage of physicians, dentists, nurses, health educators, clinics, and hospitals. At times, the region has been a repository of underqualified and unqualified health practitioners, and it remains an area where a few unethical pharmacists and physicians trade in prescriptions for painkillers. The Appalachian region is also the place where many effective innovations and creative advances in health care have originated. With nearly 25 million people living in a 205,000-square-mile area, Appalachia has been characterized as a place with pervasive health disparities and limited health care infrastructure and services.a It is a region with environmental , economic, and social conditions that contribute to poor health and substandard health care.Although knowledge about the health of Appalachians and its underlying determinants is growing, much is still unknown. This volume takes a broad perspective by focusing on the health of all Appalachians, both residents of Appalachia and those who have migrated from the region. As some researchers have noted,“the facts about health in the mountains of Appalachia have been slow to emerge” (p. 1).1 There are even fewer facts, mostly outdated, about the health of the millions of people who have migrated from Appalachia into urban areas and their descendants . Many of these migrants have settled in or near metropolitan areas across the nation, and they may be experiencing health disparities similar to those of their rural Appalachian counterparts. Useful information about the health of Appalachians has yet to be compiled in a comprehensive and cohesive manner, limiting the education of students, health practitioners, and policy and decision makers. This situation has hindered the ability to translate what is known about 2 Appalachian Health and Well-Being the determinants of Appalachian health into effective health policy and health services delivery. It has also restricted the identification of gaps in our knowledge about Appalachian health and limited our understanding of the strategies needed to decrease the health disparities affecting rural and urban Appalachians. This volume draws on a multidisciplinary group of researchers and clinicians, many of them nationally renowned for their work, to document what is known about the health of Appalachians, identify areas in need of further investigation, and assess the implications of this knowledge for policy development. This introduction sets the stage for these discussions by reviewing some of the earlier literature, examining some of the major developments in the history of health and health care in the region, defining some of the basic concepts related to the topic of Appalachian health, explaining some of the key methodologies used, and outlining the overall structure of the volume. Historical Background An exhaustive listing of historical resources relating to health in Appalachia is beyond the scope of this work. However, eight publications thematically similar to this volume illustrate the progress, or the lack thereof, made from the 1950s through the early 2000s.b Report to the Council of the Southern Mountains on Health Care Services in the Southern Appalachian Region. Published in 1955, this report by the Rural Life Council at the Tuskegee Institute discusses health conditions ; the availability of physicians, nurses, dentists, and institutional health care services such as hospitals and clinics; and the geographic distribution of these services in the region (then defined as 257 counties). In fewer than thirty pages, this highly quantitative analysis identifies the problems and some of the policy issues inherent in the health care systems of the southern mountains. What stands out is how difficult it was to collect health data at that time, forcing the researchers to be quite innovative. At one point, in the absence of any health indicators other than basic mortality data, the report uses “Rejection Rates of White Men Given Selective Service Examinations” as a proxy measure for Appalachian health status. Though aware of the medical, age, gender, and racial deficiencies of this data set, the researchers considered it the best metric available. Introduction 3 Although the report found the data on the relative health status of Appalachians to be...