More on rural health

The Long Road to Rural Health
story by Elizabeth Zubritsky

For rural health care workers like Linda Boone, tracking down patients is just the beginning. These days, there are new problems at the end of almost every country lane.

Linda "Bird Dog" Boone always gets her man. Or woman. Boone is a registered nurse with the Northampton County Health Department. Some days she makes house calls to check on people who aren't able, or willing, to make the trip to the clinic. She might look in on them after they've been released from the hospital—drawing blood, changing bandages, and making sure they get enough to eat. Sometimes, she makes surprise visits to see if patients are taking their medicines properly. And if patients aren't home when she arrives, she tracks them down. She checks their usual hangouts, stops by their workplaces, and talks to their neighbors and friends.

"If I bump into someone I've been looking for in the parking lot at the grocery store, that's where I do my work," Boone says.

Only five primary-care physicians practice medicine in Northampton County. That's one doctor for every 4,000 people. The average in North Carolina is one doctor for every 1,300 people. And the county doesn't have its own hospital. If you live in Jackson, the county seat, the closest hospitals are 20 to 30 miles away, in Roanoke Rapids and Ahoskie. The nearest major medical center is in Raleigh.

If you own a car, it's not too hard to make the trip to a medical center. If you don't, you can wait for a van from the senior center or the health department. But don't forget to call three days in advance. And you'd better plan to spend the whole day, because the van has to pick up other people, too.

"Without a doubt, transportation is one of the biggest issues for residents of this county," Boone says. "The elderly, especially, can't drive themselves and have to pay to go anywhere. Many people rely on the van service, but sometimes it drops people off before the clinic opens. We come to work and find mothers standing outside in all kinds of weather with their babies."

Twenty-five years ago, the situation in Northampton County looked even worse. In the western part of the county, there were only two physicians, both practicing part-time. Young doctors simply were not replacing the older ones as they retired. Nurses were nearly as scarce.

"There was a time when we couldn't recruit nurses," says Sue Gay, director of nursing and acting health director at the Northampton County Health Department. She says it's still hard to find specialty nurses. It took about six months to hire a nutritionist.

But Gay says it is easier to find and keep non-specialty nurses these days. A big factor in that change is the local training of new nurses. People who grew up in the area are more likely to stay, and patients feel comfortable with them more quickly.

Physicians who are trained in rural areas are also more likely to stay there, says Thomas Bacon, director of the Area Health Education Centers ( AHEC) program and associate dean of the UNC-CH School of Medicine. "In general, physicians tend to settle where they are trained, and that's in places like Chapel Hill or Durham."

To train physicians in rural communities, the AHEC program, funded by state and local governments, created nine regional centers across the state. Each center works with medical schools nearby: Carolina, Duke, East Carolina, or Wake Forest. Since the program began 25 years ago, it has placed physicians in several underserved areas. The Mountain AHEC, for example, has trained 140 physicians, and more than half of them have stayed in the mountains. There has been similar success with nurses, dentists, pharmacists, and other health-care professionals.

But training doesn't always mean rural people learning from city doctors and medical schools. The AHECs have their own faculty of local professionals who teach health-science students in a variety of fields. One goal of these programs is to show students what rural practice is really like, says Nancy Harrison, director of nursing education at the Area L AHEC in Rocky Mount. And some students decide to stay. Recently Northampton County hired an obstetric nurse and a pharmacist who both had done rural rotations there as students.

The AHECs also help overcome professional isolation, providing medical libraries, assistance with computer systems, and continuing education. The centers bring in experienced local practitioners, such as Boone, to teach seminars based on their first-hand knowledge.

One of the fastest ways to overcome isolation is to link people electronically. A few years ago, Northampton County began using a two-way video conferencing system called "telemedicine." The UNC-CH Program on Aging set up the system to allow practitioners at facilities in Northampton and Halifax counties to consult with people at Halifax Memorial Hospital in Roanoke Rapids. The researchers also use the system, one of many in the state, to experiment with different kinds of interactions—such as support groups and doctor-patient consultations—to find out which ones work well via video. Some elderly patients who used the system to talk with doctors said they preferred telemedicine because they had their doctor's undivided attention and because they didn't have to travel to an unfamiliar office, says Mark Williams, director of the Program on Aging.

Programs such as these seem to be making a difference: While most of rural America is losing physicians, North Carolina is holding steady.

Thomas Ricketts, director of the North Carolina Rural Health Research and Policy Analysis Center at the UNC-CH Cecil G. Sheps Center for Health Services Research, says research done by the Sheps Center shows that local training programs and professional support make practitioners happier in rural areas. And continuing education helps health-care professionals keep up with the rapid changes in rural medicine.

In North Carolina, one of these changeable elements is the population itself. An influx of Hispanics, as permanent residents and as migrant farm workers, is adding a language barrier. And more people are moving to rural places once they retire, so the rural population is aging.

But even more serious is the rapid increase in AIDS. In fact, AIDS is increasing faster among heterosexuals in the rural Southeast than it is among any other population in America.

"I used to see a lot of tuberculosis patients," Boone says, "but there isn't much of it anymore. Now, it's AIDS."

Even AIDS is changing rapidly, Boone says, from an acute condition to a chronic one. As researchers come up with new ways to fight the virus, people are living longer after being diagnosed. UNC-CH was one of four medical centers involved in clinical trials of a new three-drug "cocktail" to stop the progression of AIDS. The combination of drugs cut the number of AIDS-related illnesses in half—a result so promising that the National Institutes of Health stopped the trials early.

But those kinds of medicines are expensive: Some of the newer AIDS treatments cost about $3,000 per month. And the rapid spread of AIDS in the rural Southeast means the problem gets bigger all the time. The health department doesn't have the resources to provide all the residents with the help they need, forcing Boone and other practitioners to make some painful choices.

"We have to be careful about who we select for those kinds of treatment programs. The patient has to be committed," Boone says. "Once the money runs out, that's it. Nobody gets any medicine for the rest of the year."

Economics creates difficult circumstances for doctors and hospitals, too. For some practitioners, the main problem is making a living. The patient population within a reasonable distance is usually small, and, although some rural people have good incomes, many others are poor. Under those conditions, a steep increase in costs can price a practitioner right out of the market. That's what happened to obstetrical care in the early 1980s. Many family-practice doctors, especially rural ones, stopped delivering babies after malpractice insurance premiums jumped 500 percent.

"You simply can't spread around $15,000 in insurance premiums when you only deliver about 30 babies a year," Ricketts says.

The state has worked to counter such trends and retain physicians in rural areas. The Rural Obstetrical Care Incentive program, for example, paid rural practitioners part of the difference between the old insurance premium and the new one. In exchange, the physicians delivered some babies who were covered only by Medicaid.

Many practitioners don't like Medicare and Medicaid because the programs don't pay rural hospitals and physicians as much money as they pay urban ones. The differential is based on the assumption that health-care costs in rural areas are lower because salaries are lower. But Ricketts says the high turnover and increased cost of recruiting in rural areas offset any savings in salary.

Even when patients have insurance, rural hospitals have trouble because they compete with managed-care programs and with large university medical centers.

"People equate technology with quality," Ricketts says. "So they'll go to a large urban hospital for a procedure that their local hospital is perfectly capable of performing. That `bypassing' is one of the biggest problems facing rural hospitals today."

It's not just the patients who make the decision to leave their communities for treatment, Ricketts says. It's the insurance companies. Sometimes it's cheaper to go to the big medical centers because they perform procedures over and over. But it diverts money away from the local hospital.

"That patient's going to want a local hospital when he's had a car crash," Ricketts says.

Some small communities are keeping up with changes in technology and competing with managed-care systems by forming health-care networks, Ricketts says. The Roanoke Amaranth Community Health Group is one example. It was started in 1972 by local physicians who allied themselves with the hospital in Roanoke Rapids to offer more comprehensive care. The same approach has worked for Bladen County Hospital, whose administrators worked with other hospitals to create a network of services.

But even having health care available is not enough. Sometimes patients see the doctor and still don't receive adequate preventive care, Ricketts says. Then people wind up in the hospital for conditions such as seizures, diabetes, dehydration, hypertension, which could be managed elsewhere.

"Of course, people will have acute episodes sometimes," Ricketts says, "but if their care is being managed properly, they shouldn't stay long or be in and out of the hospital all the time."

To find out why primary care isn't always adequate, researchers at the Sheps Center studied areas where rates of hospitalization for such illnesses were high and found that, although some areas were under-served by doctors, others were not. Sometimes, the system just didn't work well.

One reason, Ricketts says, is that rural doctors are overworked. Research by the Sheps Center has found that rural doctors see more patients, work more hours, and are on call more often than urban doctors. Once doctors get busy, they slip out of preventive mode and into illness-treating mode, says Timothy Carey, associate professor of medicine.

One answer is to adopt an office-based approach to medicine, Carey says. Studies by Carey and Adam Goldstein, clinical assistant professor of family medicine, found that simple changes, such as giving the nurse the authority to order a mammogram or attaching a reminder to the patient's chart saying she will need one next time, can be very effective. A project led by Peter Margolis, associate professor of pediatrics, will help rural pediatric and family practices in North Carolina adopt a similar approach.

"It's one thing to come up with a solution in Chapel Hill," Carey says. "It's another thing to know it works out in the community, in places like Ahoskie."

Sometimes, lack of education prevents people from getting the most from their treatment. "Not too long ago, I came across a situation where people couldn't read their prescription labels," Boone says. "They weren't taking their medicines properly because they didn't recognize the word `twice.' A lot of times, those of us who have some education take too much for granted.

"But people won't always tell you things like that," Boone says. "A person has to have a lot of trust in you to admit he doesn't know how to read or to show you a sore he's got that won't go away."

A lack of trust can be a big obstacle for minority patients, says Linda Mayne, regional coordinator for the North Carolina Breast Cancer Screening Program (NC-BCSP), an effort of the Lineberger Cancer Center. The program, led by Jo Anne Earp, chair of UNC-CH's Department of Health Behavior and Health Education, is aimed at reducing the high breast-cancer mortality among African American women in the rural eastern part of the state by encouraging them to have regular mammograms.

"Some of the women feel `distanced' from health care," Mayne says. "They don't trust the system. Well, that makes sense once you realize some of the experiences they've had."

Mayne tells the story of a middle-aged African American woman who, as a child, went to a hospital because her grandmother was having chest pains. "Every white person who came into the emergency room—no matter how small the injury—was seen first," Mayne says. "Her grandmother was kept waiting all day. Finally, she died of a heart attack, there in the emergency room.

"That kind of discrimination is sometimes hard for us to understand because it's abstract," Mayne says. "For that child, it was terribly real. That was her first impression of doctors."

Some women also point to the Tuskegee experiments—when federal researchers allowed black men to go untreated for syphilis in order to study the course of the disease—and ask why they should trust doctors.

"The truth is, women respond better to messages about mammograms when they come from people the women identify with," Mayne says. "We all do. The difference is that some of us can identify with our doctors."

That's why the NC-BCSP uses a network of lay health advisors to talk to women about mammograms. The first lay health advisors for an NC-BCSP sister project were trained by Eugenia Eng, associate professor of health behavior and health education, back in 1990. The women were selected because people in the community already trusted them and turned to them for advice. The same concept is being used by the Sexually Transmitted Epidemic Prevention (STEP) project led by Jim Thomas, associate professor of epidemiology. Rural eastern North Carolina has some of the highest rates of gonorrhea and syphilis in the nation, and the rates are increasing most quickly among African American women. Thomas teamed up with Earp and Eng to use lay health advisors to teach African American women how to protect themselves.

But the NC-BCSP work has shown that factors other than mistrust can prevent African American women from getting the care they need. The biggest predictor of whether a woman will get a mammogram is whether her physician refers her for one, Earp says.

"African American women are less likely to receive referrals," Earp says, "but the disparity seems to be more a matter of economics and access to care than race. Poorer women or those without insurance or a regular physician are less likely to be referred. Because of that, African American women are disproportionately affected."

Even when a woman receives a referral, economics may govern her choices. A woman might have to choose between paying for a mammogram and buying clothes for her children, Mayne says. "In that situation, not getting a mammogram is a perfectly rational decision." Some women tell Mayne it doesn't make sense to spend $100 on a mammogram when they feel fine. It's just looking for trouble. "It sounds like they don't understand the importance of the test, but there's really an economic factor underlying that value," Mayne says. "What happens if she finds out she has breast cancer?"

Many women don't have health insurance, so even if they have good incomes, the hospital bills can be overwhelming. Then there's money spent on child care, transportation to a major medical center for treatment, and lost wages from taking time off work for chemotherapy. Mayne points out that many coastal women are seasonally employed as crab pickers. They can't take time off work during the crab season because that's their income for the year.

"Many women feel it's better not to know there's a problem if you can't deal with it properly," Mayne says.

Ricketts agrees that simply providing people access to services is not enough. "If people can't keep up economically," he says, "if they don't have the education they need to function, seeing the doctor regularly is not where their priorities are."

For health-care practitioners like Linda Boone, there's no time to wait for solutions to the big issues of poverty, a lack of education, and mistrust. The only practical approach is to focus on each patient and his or her community. In her words, "You learn from each person the best way to help."

On May 23rd, Thomas Ricketts was named Distinguished Rural Health Researcher by the National Rural Health Association. uralHealth

Every day, farm workers come in contact with and breathe dangerous agricultural chemicals. Thomas Arcury, senior research associate at the Center for Urban and Regional Studies, is in the first year of a four-year program to reduce farm workers' exposure to pesticides, herbicides, fungicides, fertilizers, and petroleum products. Arcury and his colleagues are talking to farmers and farm workers to find out what kinds of interventions—distributing educational materials or providing washing stations and face masks, for example—will work best.

"Whatever intervention we come up with has to be something that's good for the farmers, as well as the workers," Arcury says. "We have to understand that farmers are businessmen trying to make a living in a difficult economic environment."

For the next two years, the researchers will study 36 tobacco and cucumber farms in eight rural counties in North Carolina. They will test safety measures on 18 of the farms and measure the workers' exposure to chemicals when the season begins and ends. To evaluate the measures, researchers will compare workers' attitudes, behaviors, and chemical exposure to those of workers on 18 farms with no intervention.

Other Carolina researchers have addressed similar issues. The PHARMS (Partners against Hazards and Agricultural Risks for Migrant and Seasonal workers) project, which ended in 1995, found that many workers were unaware of how to protect themselves from chemicals, says Eugenia Eng, associate professor of health behavior and health education. Only 13 percent of workers surveyed wore socks while in the field, and only four percent wore gloves. PHARMS trained some farm workers as lay-safety advisors so they could educate others. "Someone from the University could never do what the lay advisers did," Eng says. An outsider would encounter problems of trust as well as language and cultural barriers, she says. "They inspired us."

"Infant mortality rates are elevated in rural areas among young African American mothers ages fifteen to seventeen and among white mothers ages eighteen to nineteen and thirty-five and over," says Trude Bennett, assistant professor of maternal and child health and one of the investigators who worked with the Sheps Center. "These findings point to unmet needs for teens as well as older women in rural areas."

In the year studied, birth rates for women ages 18 to 19 were markedly higher for women in rural counties than for those in metropolitan counties. For teenagers ages 15 to 17, birth rates were equally high in rural and urban areas.

Rural residents tend to have high rates of poverty and unemployment, low educational levels, and poor health status compared with urban or metropolitan populations, Bennett says. Rural dwellers have less contact with physicians and reduced access to appropriate specialty services. "These are significant risk factors for a number of health problems, including infant mortality and low birthweight," Bennett adds.

"The most important factor in preventing infant mortality is getting premature babies to neonatal intensive care units right away," says Milton Kotelchuck, professor of maternal and child health. "That's where some rural areas are at a disadvantage. They just don't have the same access to health care."