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A Healthy Attitude: Rural Leaders in Tenn. County Organize to Address Well-Being

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Lunch time at Sam’s Corner: From left to right are Sarah G. Brown, a member of the Tracy City city council and a home visitor with Prevent Child Abuse Tennessee; Sofia Leon-Meza, Grundy County public health educator with the Tennessee Department of Health; Julie Willems Keel, program director at Mountain TOP; Emily Partin, family resource center director, Grundy County Schools; Vickie Harden, assistant professor of social work at Middle Tennessee State University; and (not pictured) Sheila Beard, mental health liaison with Head Start and a board member of the South Cumberland Community Fund. Photo by Shawn Poynter

Grundy County, Tennessee, ranks near the bottom of the state in the County Health Rankings and Roadmaps. But that hasn’t stopped the small county from initiating a top-tier response to improving community health. In the new rankings released today, the county improves its position from a last-place 95th to 93rd.

It’s lunchtime at Sam’s Corner restaurant in Coalmont, Tennessee. Conversation wafts around the room, along with the aroma of freshly baked cornbread and vegetable soup.

Grundy County, Tennessee

Red-checked oilcloths cover the tables, which surround a pot-bellied stove. A group of six women is gathered at one of the larger tables, conversing while they await their orders.

When the steaming food arrives, the talk slows a bit, but it doesn’t stop. The subject: how to improve community health. And in Grundy County, Tennessee, that means there’s a lot to talk about.

“It all goes back to what my mom and dad said,” says Emily Partin, one of women at the large table, referring to efforts to address the county’s difficult health issues. “You have to bloom where you’re planted.”

In previous years, rural counties have tended to score below their urban counterparts in statewide comparisons. (Read the Daily Yonder’s report on last year’s rankings.)

That’s not always easy. Last year rural Grundy County ranked last in Tennessee in its “health outcomes” in the annual County Health Rankings and Roadmaps report. There are signs of change. In this year’s rankings, released today, Grundy County moves up two position in its health outcomes, from 95 (last place in the state) to 93.

But at the lunch table, two months before the release of the new report, the women aren’t focused on their position on the list. (“For us to move up, someone else has to move down,” Partin says. “And we don’t’ want to wish that on anybody.”) But they are focused on improving their residents’ health.

They have a lot to show for it:

  • Smoking cessation programs.
  • School-based behavioral telehealth.
  • Parent training and support.
  • An invigorated nonprofit sector.
  • Improvements in the child-welfare care system.
  • University partnerships.
  • Community-wide fitness initiatives like a walking challenge.
  • And mile after mile of trails with stunning views, and more.

The programs have grown from local leadership, with outside technical assistance and funding at key points along the way.

So how does a county that lies near the bottom in Tennessee’s health rankings create a top-tier effort to change?

The former Grundy County High School, vacant since the 1990s, is being converted to a one-stop-shop for family and community services. The first floor is scheduled for occupancy this fall. (Photo by Shawn Poynter).

Where to Start?

Partin grew up in Grundy County and moved away for college and a career as a licensed professional counselor. She grew up in Tracy City, a town of about 1,300, which, like most of Grundy County, lies atop the Cumberland Plateau. The plateau offers million-dollar views of the Tennessee Valley but little economic opportunity, especially since the coal-mining industry pulled out in the 1980s. Partin left home about the time the last of the coal did. “I thought I was never to return,” she said.

But family ties mattered. After 20 years away, she went back to care for her father. She thought she’d stay about six months. That was 19 years ago. Partin got a job as the Grundy County Schools family resource center director and got re-involved inthe community.

As a young person, Parton attended Grundy County’s single high school, then located on the southern end of the county in Tracy City. The sturdy, two-story brick structure from the 1930s was a source of community identity and pride, Partin said. In the 1990s, the board of education built a new school.

“One day they just told the students, ‘Pick up your stuff and we’re leaving,’” she said. “And they picked up their books and they left everything just like it was. It was like a ghost town.”

Interior spaces are being designed for the county school system’s family resource center, behavioral health services, community classes, and other organizations. (Photo by Shawn Poynter)

The building sat vacant for years. A community group used the auditorium as a movie theater until they could no longer get movies in film format. Without the funds to purchase a digital projector, the theater shut down. Sports teams sometimes practiced in the gym, and occasional fitness classes were held there. Otherwise, the school building sat empty – its red-brick edifice a reminder of its former importance.

After an unsuccessful effort to convert the building to a trade school, Partin and others came up with the idea of turning the old school into a one-stop shop for a variety of family and community services: the school’s family resource center, a primary medical care office, mental health services, nutrition assistance, financial management classes, community college courses, and other programs. “Anything that would get someone on their feet and able to work and provide for their family,” Partin said. Several agencies have supported the renovation, with the Southeast Tennessee Development District helping facilitate the funding effort, Partin said.

The building’s history makes it an ideal setting for a community-services center. “When families are needing help, if there is one place that would feel inviting, it would be that building,” Partin said.

A committee of volunteers got to work, but the pace of progress was slow at times. The size of the steering committee began to shrink. The attrition concerned Partin until she realized the volunteers weren’t quitting; they were just moving on to new work.

“The people who were dropping off weren’t just dropping off the face of the earth,” she said. “They were starting something else.” What had felt like decline was a step forward. “You just have to trust people,” Partin said.

The Grundy County Health Council meets in the Extension Service building in Coalmont, Tennessee, in January 2019. The council gathers representatives from agencies across the county to share information on health-related topics. (Photo by Shawn Poynter)

Community Philanthropy

That trust turned out to be well placed. At roughly the same time that Partin and others began planning the school renovation, other initiatives got underway, including an effort to create a community foundation.

When it came to formal philanthropy, Grundy County was not on the map. That changed with the 2012 establishment of South Cumberland Community Fund, which serves the plateau portions of Grundy, Franklin and Marion counties.

“Previously, there were no local philanthropic resources,” said Jack Murrah, an early proponent of the foundation. A resident of Monteagle, Murrah moved to Grundy County after a career at the Lyndhurst Foundation in Chattanooga.

With professional expertise and community contacts, volunteers found ways to tap community wealth. The University of the South at Sewanee, a liberal arts college located on the plateau a few miles from Grundy County, played a big role, Murrah said. Early support also came from second-home owners and residents who moved to the area for its natural amenities. A major challenge grant from one the county’s second-home owners, Howell Adams, got the operation off the ground, and the community met the fundraising challenge.

Since 2012 the South Cumberland Community Fund has awarded more than a half million dollars for community-minded projects to 45 different organizations.

The organization provides more than money, Murrah said. “[The fund] supports the nonprofit sector with technical assistance and training,” he said. “They have helped with capacity building and building a network within the nonprofit sector.” The foundation also sponsors training, such as courses through Nashville’s Center for Nonprofit Management.

“I think we’ve added some energy to the efforts of a lot of different groups,” Murrah said.

Town and Gown

Philosophy Professor Jim Peterman directs the Office of Civic Engagement at the University of the South. (Photo by Tim Marema)

The University of the South has a long history of involvement with communities on the Cumberland Plateau. But the institution began to take on new roles after the 2010 arrival of Vice Chancellor John M. McCardell Jr. and his wife, child education advocate Bonnie Greenwald McCardell. Besides helping start and sustain the community foundation, the school also established the Office of Civic Engagement, which connects the university directly to local agencies.

The program takes its cues from local institutions, many of which are working on health-related issues, said Jim Peterman, a philosophy professor who also heads the Civic Engagement Office.

“Our orientation for working in the community, right from the outset, was not the traditional service model,” Peterman said. “It has been to work in communities in ways that build capacity for them to achieve their own aspirations.”

The office facilitates student internships, community-focused research, and an AmeriCorps VISTA program with local agencies, among other activities.

“The work that we are doing will emerge out of relationships,” Peterman said. “We don’t know for sure what that is going to be ahead of time.” That’s a different way of working for the 150-year-old Episcopal institution.

Sewanee’s alumni connections have also come into play. Partnerships focused on child development with Yale University are one result. Another recent alumnus stayed in the area after graduation to create a personal loan institution to compete with less consumer-friendly payday lenders.

Middle Tennessee State University staff have also been active in Grundy County. Vickie Harden, an assistant professor in social work at the school in Murfreesboro, has arranged internships and research and secured grant funding for projects in the county. She got to know the county while working for Volunteer Behavioral Health, a nonprofit mental health agency.

Harden and Sheila Beard, who also worked for Volunteer Behavioral Health at the time, wrote a federal grant proposal to help organize communities on the plateau around healthcare needs. Beard is now the mental health liaison for Head Start and serves on the South Cumberland Community Fund Board.

Harden said it’s important for higher education to get involved in health-related projects because they can provide resources and link local people to bigger issues. “I think there’s an opportunity there to not just bring in manpower but bring in thought leadership,” Harden said. “[We can] possibly bring in folks who can look at federal and state policies and be able to articulate what’s happening on the ground to policy makers.”

The Mountain Goat Trail runs through Tracy City, where a statue and rail section commemorate the town’s historic connection to coal and the railroad. The tracks were pulled out in the 1980s. After years of disuse, the railroad bed is being converted to walking trails that will connect Tracy City, Monteagle, and Sewanee. (Photo by Shawn Poynter)

Hit the Trail

One indicator of health is residents’ access to recreational facilities. Grundy County residents see progress on this front. The Mountain Goat Trail Alliance, for example, is converting an old railroad right of way into recreational trails.

Metro vs. Nonmetro: All five of the best-rated counties in Tennessee are metropolitan. All five of the lowest-ranked counties are rural. Find your county’s health-ranking information.

Completed portions of the project include a 3.5 mile-section that runs through Tracy City and a longer section that runs through Monteagle to Sewanee. Construction is scheduled to begin in the fall of 2019 on three more miles that will connect the two segments.

It’s not easy to convince people who live in an economically distressed area that trails are the best use of public investment, Partin said. But there’s a direct link to improving community health. “We see that as part of the built environment that’s going to help address some of our health disparities,” she said. “Even though you are a rural county and there are lots of grassy areas, there’s really no place for families to get together and get exercise like pushing a baby stroller.”

Only a third of Grundy County residents say they have access to exercise opportunities, such as walking trails.

With easily accessible and family-friendly trails, walking is much more practical, Partin said. Local people have started competing in a national walking challenge. Partin’s church, Tracy City First United Methodist, had about 60 people sign up for the challenge last year. Together they logged about 11,000 miles and engaged in friendly competition with other groups. They expect a similar turnout for this year’s challenge.

And the Mountain Goat Trail keeps growing. Grundy County government acquired 17 more miles of railroad right of way in 2018. That will extend the trail all the way to Palmer, a former coal camp that lies just a mile or two from Savage Gulf State Natural Area.

Foster Falls off Highway 41 in Grundy County is part of South Cumberland State Park, the largest park in the state system. (Photo by Shawn Poynter)

The Great Outdoors

Old railroad beds make for smooth, well graded trails. Savage Gulf State Natural Area offers the other kind. Savage Gulf is part of South Cumberland State Park, a non-contiguous holding of 31,000 acres covering 10 units in four counties. It’s the largest park in the Tennessee system. Besides Savage Gulf, the park includes iconic features of the Cumberland Plateau – gorges, waterfalls, sandstone cliffs. The park’s trails range from multi-day backpacking scrambles to short strolls on paved, wheel-chair accessible walkways.

County leaders know Grundy’s natural assets could create jobs and businesses based on the recreation economy. Rural counties with good recreational amenities tend to retain more population and perform better economically than other rural counties, studies show. (Read about one of those studies

The southern Cumberland Plateau rises about 1,300 feet about the Tennessee Valley near Grundy County. (Photo by Shawn Poynter)

in the Daily Yonder.) Tapping the economic potential takes time, however. For example, there are few tourist accommodations outside Monteagle. Some families are starting to supplement their incomes with short-term rentals through services like AirBnB. (This type of economic activity requires internet access. The county has access through a telephone cooperative and four for-profit providers. National industry reports, which are widely criticized for inaccuracy, say Grundy County access speeds range from 5 Mbps to 1 Gbps.)

Although Partin worries that the service-industry jobs that come with recreation won’t pay enough to significantly improve family economic conditions, there aren’t a lot of other options. Coal employment – the county’s former economic underpinning – has been gone for more than a generation. A common side business, chicken farming, faded when the industry demanded that farmers get big or get out. Today, people may make some money selling their second-growth timber, and small clear cuts are numerous throughout the county.

Partin said finding jobs that pay better requires driving “off the mountain.” (Locals refer to areas not atop the plateau as “off the mountain.”) Some go to Chattanooga, about an hour’s drive each way. A little farther in the other direction lies Murfreesboro, with a Nissan plant, Veterans hospital, and an Amazon fulfillment center. Either direction, the commute includes descending and ascending the 1,300-foot escarpment at the beginning and end of the day. That results in Grundy County residents having above-average commute times, another measurement used in the health rankings.

But the recreation economy is having an impact on local business. One establishment that has made the transition from the coal-town era to a more tourist-oriented economy is the Dutch Maid Bakery in Tracy City. The bakery was founded by Swiss immigrants in 1904. Their first customers were the coal-town residents, many of whom had also immigrated from Switzerland. Today, the bakery still serves locals. But they also have a customer base among campers and second-home owners, according to a video produced by Bake Magazine.

Vickie Harden (left to right), Emily Partin, and Julie Willems Keel tour the renovation at old Grundy County High School, which is being converted into the South Cumberland Learning and Development Center. (Photo by Shawn Poynter)

Families First

Another set of community efforts has addressed parenting and children. Grundy County was the first rural site (and just the second in the entire state) to create a safe-babies court team. The program works with parents who have entered the child-welfare judicial process with a child 3 years old or younger. Rather than taking a merely judicial approach, advocates help families gain access to programs that can improve conditions at home.

The safe-baby program manages short-term family crises while aiming for long-term impact, said Katie Goforth, who manages the AmeriCorps VISTA project at the University of the South.

“In baby court, even though our focus is on that baby and that family, there’s an even bigger chance that the next baby being born into that family is going to get the benefits of the energy, time, and resources we’ve put into that family,” said Goforth, whose background is in behavioral health.

For other parents, Partin has started Discover Together. She calls the program a “place-based family co-op for families with children from birth to 5 years old.” Twenty families are participating. They gather twice a week for two to three hours for multi-age activities that mix toddlers, preschoolers, and parents. The multi-age mixing can surprise people.

“That mother may say, ‘Well, my 6 month old is not going to sit there and listen to that book being read,’” Partin said. “But guess what? In three or four weeks, guess who’s crawling over to be right in the middle of the 4 year olds?”

The long-term goal is for parents in the program to share what they learn. “We are hoping that they are going to become the ambassadors that take the information out to others,” Partin said.

But Wait, There’s More

Several other noteworthy community health initiatives are underway, many of them supported by VISTA workers sponsored through the University of the South and the South Cumberland Community Fund. There’s a health ambassadors program that will work through church members to do peer health education, a healthy-cooking program for families that participate in the Supplemental Nutrition Assistance Program, a faith-based housing improvement mission called Mountain T.O.P., a state-mandated County Health Council that brings together officials from different agencies around the county to share information. And some efforts have sprung up from families that simply want to give something back to the community. One couple who work in healthcare professions, for example, volunteers their time to teach community courses in managing type 2 diabetes. And, in what must be the most obvious sign that change is afoot, the Smokehouse Lodge and Cabins, a Monteagle restaurant that specializes in barbecue, has added healthy menu choices.

Emily Partin points to work being done on the grounds outside the old school. (Photo by Shawn Poynter)

Bottom Line

Despite Grundy County’s improvement in the 2019 rankings, the county remains near the bottom of Tennessee’s 95 counties. So are the programs making a difference?

“What stands out in Grundy County is that they have decided to take action,” said Aliana Havrilla, a community coach with County Health Rankings and Roadmaps. “There’s a core group of people in the community working to improve health outcomes and strengthen the community. And they are reaching out to others to include them in the journey.”

Harden from MTSU agrees that the effort is important. “I see how many people are struggling, but I also see them strengthen that community,” she said. “That’s what has kept people moving forward. … They’ve been in that community for generations and they just don’t give up.”

One More Stop

The first floor of the South Cumberland Learning and Development Center – the one-stop services center that is going into the old Grundy County High School in Tracy City – will be ready for occupancy this fall, Partin said. Renovation is underway on the second floor. Prevent Child Abuse Tennessee, which provides in-home parenting support, and Volunteer Behavior Health have signed letters of intent to use space in the center. Other potential tenants are a primary care clinic and community classes and workshops. Partin hopes community college courses and other educational services will eventually be part of the mix.

The old high school auditorium is expected to get a digital film projector after the renovation is complete, allowing the space to be used once again as a community cinema. (Photo by Shawn Poynter)

On the entertainment front, first-run movies are likely to return to Grundy County. The old school auditorium has a digital projector ready to be installed as soon as the dust settles on the renovation, Partin said.

The old gym, with a hardwood floor still in excellent condition, is next on the list for repairs. The county is using a diabetes prevention grant to help convert the space into a community fitness facility.

In the midst of many inconspicuous changes, the high school project stands out as tangible evidence of change, said Julie Willems Keel, who works in community development initiatives with Mountain T.O.P.

“It’s a real sign of hope – that things can change and progress. Not everything is decaying and falling apart,” she said. “We’re integrating our community’s history with forward progress.”

Disclosure: The County Health Rankings and Roadmaps is a project of the Robert Wood Johnson Foundation. The Center for Rural Strategies, which publishes the Daily Yonder, receives funding from the foundation.

This article was originally published by the Daily Yonder.

Appalachian health

Amid Measles Outbreaks, Debate Grows Over Religious Exemptions from Vaccination

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Measles, mumps and rubella vaccines are seen in a cooler at the Rockland County Health Department in Pomona, N.Y., Wednesday, March 27, 2019. Photo: Seth Wenig/AP Photo

This article was originally published by the Ohio Valley ReSource.

Toni Wilkinson has seven children, three of them under six, and all of them home-schooled. So her house on a Lexington, Kentucky, cul-de-sac is rarely quiet.

Listen to the story.

Just inside the front door are bins filled with shoes, piles of jackets on a long bench. Across the room is the family library, crammed with school books. Crowded among them are controversial titles critical of vaccinations, the books Wilkinson used in her own homework researching vaccines.

“I just started to have questions, it was just this lingering doubt that I can’t really explain,” she said.

Toni Wilkinson said faith guided her decision not to vaccinate her three youngest children. Courtesy: Toni Wilkinson

As those doubts grew over the years, vaccinations for her children decreased. Her two oldest children are fully vaccinated. The next two received the required shots only until middle school. Her three youngest are not vaccinated at all.

Wilkinson said her faith ultimately informed her choice. She learned that stem cell tissue from abortions had been used to produce some vaccines.

“And so that became a big issue for me because we’re very pro-life,” she said.

Kentucky is among 47 states that allow some form of religious exemption from vaccination requirements for children to attend public schools. Kentucky is also among 22 states that have reported cases of measles this year.

Two decades after the U.S. had essentially eliminated measles, the viral disease is roaring back. Health officials recently reported nearly 700 cases of measles in the U.S., the most in 20 years, and they point to a growing trend against childhood vaccination as a cause. Some measles outbreaks in New York and Ohio have been associated with religious communities opposed to vaccination, and that has intensified the debate about religious exemptions.

Kentucky and neighboring states in the Ohio Valley provide a case study and the potential for some timely lessons on the public health implications of vaccination exemptions. While Kentucky and Ohio allow the exemptions, West Virginia does not.

Vaccine History

According to the Centers for Disease Control and Prevention, a few vaccines were developed using human cell cultures derived from two legal abortions in the 1960s. Researchers maintain those cell lines in laboratories and no additional fetal tissue has been added since they were originally created.

A 3D graphical representation of a spherical-shaped, measles virus particle. Courtesy: CDC

But Wilkinson’s concerns resonate with others who staunchly oppose abortion.

Kentucky and Ohio allow parents with religious objections such as these to enroll a child in school without proof vaccination. West Virginia does not.

“West Virginia started having state laws about vaccines in the late eighteen hundreds and there’s never been any type of religious or personal belief exemption in our laws,” said Jamie Lynn Crofts, a civil rights attorney in Charleston, West Virginia. She said with its 98 percent vaccination rate, well above the national average, West Virginia could be a model for other states.

“Looking at our scheme and how effective it’s been could be a great guide to states who are looking to reform their laws to stop outbreaks in the future,” she said.

Vaccination rates in Kentucky and Ohio are 92.6 percent and 92.1 percent, respectively, both below the national median rate of 94.3 percent.

Crofts said how you feel about vaccination can depend on when you were born. Most Millennials, for example, have no personal experience with measles and may not see it as a threat.

The CDC reports that before the measles vaccination program started in 1963, an estimated 3 to 4 million Americans got measles each year. Only about 500,000 cases were reported each year to the CDC. Of these, 400 to 500 died, 48,000 were hospitalized, and 1,000 developed encephalitis (brain swelling) from measles.

While the current outbreak seems insignificant against those historic numbers, health officials are concerned. The public health benefit of a vaccination depends in part on what’s called “herd immunity,” achieved only when a high percentage of vaccination keeps the disease at bay. A study from Oxford University found that 19 out of 20 people need to be vaccinated to maintain herd immunity against measles.

Religious Reservations

No major American religion explicitly seeks to forbid vaccines. Some within the Catholic church encourage vaccination. But a subset of church members like Wilkinson reject vaccines on moral grounds because of the past use of fetal cells in some vaccine development.

That religious belief is a key part of a lawsuit brought by the parents of a student at Assumption Academy, a private school in northern Kentucky. Most of the students were not vaccinated, resulting in a recent outbreak of 32 cases of chickenpox. When the Northern Kentucky Health Department curtailed school activities to curb the spread of disease, some students and parents sued, arguing that it violated their rights. The school posted a press statement on the outbreak on its website explaining its beliefs about the vaccine.

“While the Catholic Church does not oppose vaccinations in principle, it does consider as morally illicit the development of vaccines from aborted fetal tissues,” the statement read.

It’s not the first time outbreaks have been linked with a specific religious community.

The CDC connected unvaccinated members of the Amish communities in Ohio to the last record-breaking outbreak in 2014. Researchers found that people in those communities made up nearly half of the cases in the national outbreak.

Dr. James Gaskell is commissioner of the Athens City-County Health Department in Ohio. He remembers that the 2014 outbreak had a lingering impact on the Amish community.

The Amish were resistant to vaccination at first. But, he said, after a few cases of measles, when they recognized the severity of the disease, some changed their minds and began to immunize their children.

Gaskell said that outbreak began after Amish men traveled to the Philippines, which still has a high number of measles cases.

A current measles outbreak in New York has similar origins, Gaskell said. Orthodox Jewish men traveled to Israel and some returned infected with measles, which spread into their community where many others are not vaccinated. The New York outbreak has sparked debate over limiting or eliminating religious exemptions there.

Law Changes

In Kentucky and Ohio, lawmakers are moving in the other direction even though both states have vaccination rates below the national average.

“There has not been any talk about eliminating exemptions to vaccines in Kentucky that I’m aware of at this point,” Kentucky’s Public Health Commissioner Dr. Jeffrey Howard said.

Howard said he supports vaccines and that there are a lot of misunderstandings and myths surrounding them. But, he says, Kentucky is a place where people want to protect personal liberties such as whether or not to vaccinate a child.

He said requests for exemptions are rising and lawmakers are making access to exemptions easier.

In 2017 Kentucky legislators removed the requirement that a physician must sign a request for a religious exemption. Now parents simply sign and submit a notarized form. A bill pending in Ohio would make similar changes to increase access to exemptions.

Dr. Scott Gottlieb was commissioner of the federal Food and Drug Administration from 2017 until earlier this month. He is now a resident fellow at the American Enterprise Institute.

Gottlieb said religious exemptions are on the rise along with the number of cases of measles.

“I think it would be highly unfortunate if we started to see governments take a more activist role, particularly the federal government, in terms of mandating vaccines, because I think these are issues that have long been held left to state supervision for a lot of good reasons,” he said.

Gottlieb said the surge in the number of infections reflects “a tragic reluctance to embrace what is one of our most effective and safest vaccines.” And that will soon force health officials to make tough policy decisions.

“We’re at the point right now where we’re starting to see outbreaks of such a scope that we are going to reach a tipping point and perhaps some point soon.”

Belief and Backlash

Toni Wilkinson is aware of the controversy around vaccination decisions such as hers.

Wilkinson said her decision has come with backlash, including conflicts within her family and, scathing comments on social media. She and her friends who have made similar choices have become wary of even discussing vaccines with people.

Amid the home school library at her house are books on vaccination like Miller’s Review of Critical Vaccine Studies. Photo: Mary Meehan/Ohio Valley ReSource

“You read some of the stuff that people say and it can get really nasty. Like, you know, ‘These people shouldn’t be able to have children if they’re not going to vaccinate them.’ It can get very ugly.”

She said she feels certain in her decision. “God places children in families for a reason,” she said. But she adds that she still has brief moments of doubt.

“I think there was still a little fear of like, what if my child got what is considered a vaccine-preventable disease, what am I going to feel?”

“I think there was still a little fear of like, what if my child got what is considered a vaccine-preventable disease, what am I going to feel?”

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Appalachian health

2019 County Health Rankings Cite Housing as a Foundation for a Healthier Future

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Overlook North, a 60-unit low-income housing tax credit family development built in 2002 in Oakland, Maryland. Photo: Courtesy Garrett County Community Action Inc.

Healthy living begins in the home. Secure, affordable housing is critical to living long and well.

That’s according to the recently released 2019 annual County Health Rankings, a collaboration of the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

Ranking the health of nearly every county in the nation, the report’s authors write that their findings “illustrate how where we live affects how well and how long we live,” and underscore “what each of us can do to create healthier places to live, learn, work, and play – for everyone.”

The focus of this year’s report is housing. Health outcomes, the authors continue, “are shaped by a range of factors that are heavily influenced by where we live,” including our behaviors, access to care and nutrition and social and environmental factors.

If housing costs exceed 30 percent of monthly household income, that household is considered severely cost burdened. Nationwide, according to the report, more than one in 10 households spend more than half of their income on housing. This burden is associated with food insecurity, child poverty and self-assessments of poor health, according to the authors.

Communities across the country are rising to this challenge with comprehensive strategies that include housing rehabilitation loans and grants, rapid rehousing initiatives, mixed-income development and civic engagement.

One such is the Appalachian community of Garrett County, Maryland, where affordable-housing initiatives are not only meeting immediate needs but promoting economic development.

View west along U.S. Route 40 Alternate (National Pike) crossing into Garrett County, Maryland from Allegany County, Maryland. Photo: Famartin/wikimedia

One ‘Unforeseen Event’ from the Street

For Aliana Havrilla, a community coach with the County Health Rankings and Roadmaps program, the single-most disturbing statement in this year’s report is that hundreds of thousands of households are but one unforeseen event – an illness, a job loss or even just a drop in hours – from losing their home.

According to the report, in 2016 nearly 900,000 households faced evictions.

That so many families and individuals have such a tenuous hold on secure housing, Havrilla asserted, “is a conversation that we don’t often have, but that we should be having.” It’s a conversation this report aims to advance.

For those who are able to remain in their home, struggling to meet a mortgage payment often means foregoing medical care or extending a few groceries beyond their capacity to nourish, triggering a cascade of health concerns.

While no region or demographic has been immune, the researchers determined that half of all rural counties have experienced an increase in severe housing cost burden since the housing crisis of 2006 to 2010, and that nearly one in four black households spend more than half of their income on housing.

Garrett County is Maryland’s westernmost county, abutting the state’s West Virginia and Pennsylvania borders. According to the County Health Rankings, it ranks 15th among the state’s 24 counties in health outcomes, health behaviors and clinical care, and 17th in quality of life.

The Garrett County Community Action Committee is a private nonprofit agency that works to build economic security for lower-income families and households. Affordable housing has been an area of concerted focus.

Duane Yoder, the agency’s president, said that while the home-ownership rate in the county is high, much of the housing stock is mobile homes that are in poor condition.

“One of the things that’s happened is that the community has been successful in creating jobs,” Yoder said. The county’s unemployment rate was once three times that of the state and the nation; it’s now roughly equal to those rates. But many of those jobs are in the services industry, and the pay is moderate to low.

“What that does in terms of housing,” Yoder explained, “is that it has created what our economic-development people and the business community are saying is an absence of affordable workforce housing. That’s become the big economic-development issue in the county.”

Affordable workforce housing is housing that is considered to be reasonably affordable for moderate to middle-income workers.

A primary concern for Garrett County, like for so many rural Appalachian communities, is the aging of its population – young people leaving in search of more and better opportunities. A declining population has a ripple effect, with implications for a community’s health. It can make it more difficult to recruit health care professionals and result in the closing of the local hospital.

So the community asked itself, Yoder said, “Can we do something to promote affordable housing that is targeting workforce-level incomes, and see if that stabilizes the population – see if that creates a younger population with children and a new economic energy that comes out of the younger households.”

The county commission has appropriated more than a million dollars the past couple of years to the Garrett County Community Action Committee for a down-payment assistance program. The stipulation is that the house must be in Garrett County.

The groundbreaking for a 90-unit senior housing development called the Meadows at Mountain Lake, completed in 2017 in Mountain Lake Park, Maryland. Photo: Courtesy Garrett County Community Action Inc.

The community has also invested in mixed-income rental housing, with units available for different income levels.

So while striving to bolster its residents’ quality of life in the here and now, the community is aiming toward a healthier future.

“It’s an economic-development strategy trying to address the issue of the decline in our population,” Yoder said. “We’re using housing as a strategy to promote economic development.”

Reason for Hope

The County Health Rankings authors write that “when too much of a paycheck goes toward the rent or mortgage, it makes it hard to afford the doctor, cover utility bills, or maintain reliable transportation to work or school. Owning a home can help build savings, providing stability and wealth over time.”

This is the 10th year of the rankings, Aliana Havrilla notes. “What gives me hope, broadly, is that we have knowledge and understanding of what drives better health.” That knowledge is now being coupled with practical strategies, she said. “We see a lot of these promising approaches and ideas across the country.”

“We’re really starting to understand both the drivers and the opportunities. That’s what gives me hope.”

Taylor Sisk is 100 Days in Appalachia’s health correspondent.

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Appalachian health

Kentucky’s ‘Too Low and Too Slow’ Response to the Nation’s Worst Hepatitis A Outbreak

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Pharmacist Mindy Howard gives Jennifer Cantrell, pharmacy tech, her second dose of the Hepatitis A vaccine inside Med Zone Pharmacy in Prestonsburg, Ky. on Jan. 9, 2019. Since a statewide outbreak of Hep A was declared in November 2017, the state has had more than 3,500 cases and 22 deaths. Photo: Nikki Boliaux

Kentucky’s Hepatitis A outbreak is the worst this century, sickening more than 4,100 and killing 43. And the state could have done more to control it.

Last spring, Kentucky’s infectious disease chief was ringing the alarm.

An outbreak of hepatitis A that already had infected nearly 400 people in Louisville was seeping into Appalachia, where rampant drug addiction provided fuel for the virus to explode across rural Kentucky.

To contain it, the drug users and homeless largely spreading the disease had to be vaccinated — and quickly.

But the challenges in impoverished rural Kentucky were huge. Drug users were hard to find and vaccinate. Thinly staffed county health departments had seen their budgets shrink. And federal vaccine money for Kentucky had run out.

“Need to move faster,” urged Dr. Robert Brawley in an April 2018 email to state health department colleagues obtained by the Courier Journal. “The virus is moving faster than we and (local health departments) are … immunizing persons (at) risk.”

Brawley argued that a powerful state response was needed: $10 million, including $6 million for a fusillade of 150,000 vaccines and $4 million for temporary health workers to help administer them. In an email, he also lobbied for a public health emergency declaration to bolster the case for more federal money.

But a Courier Journal investigation found his urgent pleas went nowhere. And in the months that followed, Kentucky’s outbreak metastasized into the nation’s largest and deadliest.

The Courier Journal found that Brawley’s boss, 31-year-old acting public health Commissioner Dr. Jeffrey Howard, rejected his aggressive recommendations. Amid limited state budgets, county staffing constraints and the availability of more than $220 million in local health department reserve funds — he stuck instead to a $3 million state response.

The state ultimately sent $2.2 million to local departments and declined to declare an emergency. In addition, county health departments added little to no staff to increase efforts to find and vaccinate drug users and homeless people.

Moreover, Kentucky officials never tried strategies used successfully by some of the other 16 states who fought outbreaks with limited budgets.

Kentucky didn’t seek money from the state legislature, like Michigan. It didn’t deploy “strike teams” of state health workers to counties, like Indiana.

And it waited much longer to deploy state funds than Tennessee, which earmarked $3 million after just 25 cases.

The contagious liver disease has taken a heavy toll in Kentucky, sickening 4,162 people, far more than in any other state. It has sent 2,015 Kentuckians to the hospital for costly treatment.

And it has claimed 43 lives, the highest death toll in the U.S. — including people such as former Eastern Kentucky coal miner James Ramey.

Last fall, Ramey’s organs failed, one by one, until he struggled so hard to breathe that the blood vessels burst in his neck.

In his last hours, his father raced over two hours from Martin County to his bedside in a Lexington hospital, leaning over his tubes and wires to beg him to hold on.

Ramey’s heart gave out as soon as he heard his father’s voice and felt his touch. He died Nov. 28, 2018, just over a year after the state declared an outbreak of hepatitis A.

“There’s a very good chance James would be alive” had the state done more earlier to educate and vaccinate people in Appalachia, said his sister, Brandy Stafford. “We are desperate for help in these counties. People are crying out.

“Does the state not think these people’s lives are worth something?”

Brandy Stafford and Tim Ramey lost their brother/son James Ramey to complications due to hep A.Nikki Boliaux, Louisville Courier Journal

A controversial decision debated

Howard defended his decisions, telling the Courier Journal the state used limited money to bolster vaccines in numbers that could actually be administered by small staffs in county health departments — and he was willing to seek more funding if needed.

Nurses were expensive, he said. And even with more vaccines, drug users would remain difficult to find.

None of the counties requested additional staff, he said, and some were slow to spend the state money they did get. Also, counties could pay for vaccines with local tax revenue or Medicaid reimbursements or order vaccineprovided by the U.S. Centers for Disease Control and Prevention.

Moreover, state officials consulted with the CDC, which provided more than $600,000 in cash and $1.4 million worth of vaccines, he said. And they targeted people where they could efficiently find them: jails, emergency rooms, syringe services programs and drug rehabilitation centers — efforts that public health experts praised.

But he acknowledged that in retrospect he could have done some things differently.

“I would’ve liked to be more robust in our early response in Eastern Kentucky for sure. I wish I would’ve been more bold and said, ‘Let’s move into Eastern Kentucky,’ as opposed to waiting, as we did, with the outbreak,” said Howard, who grew up in Appalachia.

“As an Eastern Kentucky guy, it’s heartbreaking to see this disease spread out in rural Kentucky. And I knew the struggles that they’d have once it started.”

Adam Meier, secretary of Cabinet for Health and Family Services, said he stands behind Howard’s choices. He said in a statement that the “challenges Kentucky faced were less financial and more logistical in nature as it related to identifying and engaging the at-risk populations.

“While hindsight might provide more context for some things now, in retrospect there’s not a single decision that I’m aware of that was made in real time, with the information available at the time, that I would change.”

But Brawley told the Courier Journal that much greater resources were needed to battle Kentucky’s spread of hepatitis A, pointing out that San Diego County in California spent more than $12 million fighting its 2017 outbreak.

After an early response that an audit deemed too weak, San Diego brought the virus under control by nearly quadrupling the vaccines administered seven months into its outbreak.

By comparison, the state general funds Kentucky spent on its outbreak amounted to less than a quarter as much, Brawley said, even as the virus ultimately infected nearly seven times as many people.

“In comparison, the Kentucky hepatitis A outbreak response has been too low and too slow …” Brawley, who resigned in June,told the Courier Journal.

“Had the state hastened its vaccination efforts, it may have more quickly reduced the risk of the disease’s spread and prevented acute cases, hospitalizations for about 50 percent of those cases, deaths and avoided millions of dollars in healthcare expenses for emergency department visits and hospitalizations.”

Now, he said, “Kentucky has the worst hepatitis A outbreak in the United States in the 21st century.”

Kentucky’s hepatitis A outbreak is the nation’s worst, sickening nearly 4,000 and killing 40 by February 2019. Nikki Boliaux and Michael Clevenger and Chris Kenning, Louisville Courier Journal

‘His advice should have been heeded’

Others inside the health department, including nurse Margaret Jones, manager of the state’s immunization program, agreed that Brawley’s recommendations could have curbed the outbreak faster.

“We should have done more sooner,” said Jones, who retired last summer. “If we had been able to get the vaccines out early, we may not have near as many cases or near as many hospitalizations. … He knew what to do. I think his advice should have been heeded.”

Jones said others were surprised Howard didn’t follow the guidance from Brawley, a public health veteran who has been a doctor since 1975, holds specialized degrees in epidemiology and infection control, and retired from the U.S. Navy Medical Corps before joining the department in 2006. Brawley eventually left his job as chief of the state health department’s infectious disease branch and now lives in Columbus, Ohio.

Howard graduated medical school in 2014, was named acting commissioner just as the outbreak was declared in November 2017 and received his Kentucky medical license last year.

As recently as 2018, he was working on a public health master’s degree at Harvard University and was officially appointed public health commissioner in June.

A hepatitis A vaccination in the Martin County Health Department in Inez, Kentucky, on Jan. 8, 2019. Photo: Nikki Boliaux

Like Jones, others who work in rural Kentucky were dismayed that Brawley’s recommendations were ignored.

“It’s shocking that decision was made. I’m flabbergasted,” said Stacy Usher, manager of a drug prevention program in Wolfe County, which has one of the state’s highest rates of hepatitis A.

But Meier emphasized that the state’s response, led by the state epidemiologist, was guided by a public health team including epidemiologists, physicians, nurses and scientists. He pointed to county health department reserves and other sources of funding available to help address the outbreak.

Officials at the CDC and in other states haven’t criticized Kentucky’s spending decisions. For most states, they said, resources dictate public health responses.

Howard echoed that sentiment, saying that while he never had an issue with the amount of money Brawley wanted to send out, the state “had to limit our response based on the capabilities that exist.” 

Brandy Stafford visits the grave of her brother, James Ramey, who is buried in a family cemetery just outside of Inez, Kentucky. Ramey died after contracting hepatitis A. Feb. 8, 2019. Photo: Michael Clevenger/Courier Journal

Hit hepatitis A hard and fast

Given the challenges and the unpredictability of viral infections, experts said, it’s impossible to know the extent to which Kentucky’s outbreak would have been minimized with more resources.

But experts say the unprecedented hepatitis A outbreaks that have sickened more than 13,000 Americans are a reminder that states must devote more resources to preventing and controlling disease, despite a national erosion of public health budgets.

If rural health departments nationally were “properly resourced,” they might have been able to stop the vaccine-preventable disease before it sickened so many, said Dr. Michael Brumage, an assistant dean at the West Virginia University School of Public Health.

“This is something that happens in Third World nations,” Brumage said. “This should not be happening in the First World.”

Three Forks Regional Jail in Beatyville, Kentucky, on Jan. 9, 2019. The jail was under quarantine in September 2018 due to hepatitis A. Photo: Nikki Boliaux

Experts agreed that the way to bring hepatitis A under control is to hit it hard and fast. That saves money in the end, they said, because prevention always is less expensive than treatment.

“As soon as there’s a few cases, that’s the time to throw everything but the kitchen sink at it,”  said Dr. Nate Smith, president-elect of the Association of State and Territorial Health Officials and director of the Arkansas Department of Health. “Once you’ve got thousands of cases across the state, it’s hard to get the genie back in the bottle.”

Howard: Hepatitis A is usually a ‘mild disease’

Howard said he appreciates the severity of the outbreak, which has spread to 103 of Kentucky’s 120 counties.

But it would be wrong, he said, to compare hepatitis A to other diseases affecting drug users, such as hepatitis C, which afflicts Kentucky at one of the nation’s highest rates.

Howard said hepatitis A is different because “for most people that get it, is a fairly mild disease. Your liver enzymes will go up. You’ll feel bad for a few days. And it will go away. … I think it would be a mistake to equate it with HIV, hepatitis C and diseases that cause severe morbidity and mortality.”

Officials are hopeful the hepatitis A outbreak has crested. The number of new cases each week is down from 150 in early November 2018, averaging 87 a week this year.

State health officials said their plans in 2019 include working to help local departments vaccinate more regularly at jails, increase vaccinations generally, enlist more federally qualified health centers to administer vaccines, and continue to push out federally funded vaccine to counties.

But even now, too many at-risk drug users and homeless still aren’t being reached, said Dr. Martin Gnoni, an infectious disease specialist at Our Lady of Bellefonte Hospital near Ashland, one of the first areas outside of Louisville to be hit last year.

Gnoni said his area could use more epidemiologists and health department staff, as well as outreach teams in vans. To get the virus under control, Louisville’s 220-person health department blanketed vulnerable residents, administering 25,000 vaccines.

And it paid off. By May, Louisville’s cases declined steadily. The city’s all-out response led to nearly 100,000 vaccinations and was called a “gold standard” by the CDC.

But Appalachian counties have fewer resources and fewer places drug users and homeless people concentrate, which has helped the virus race through the mountains.

In January, Martin County, where Ramey lived and died, recorded some of Kentucky’s highest rates of hepatitis A.

“I guess you could have seen it coming,” said Stephen Ward, the health department director in Martin County, where more than a third of the 11,000 residents live in poverty and addiction touches nearly every family.

Steve Ward, Martin County Health Department director, speaks on the impact of hep A in his area of Inez, Kentucky.Nikki Boliaux, Louisville Courier Journal

The county gave out around 800 vaccines last year, but never got any of the state money targeted for vaccinations. Howard said he wasn’t sure why, although it did receive some federally funded shots.

Regardless, Ward said Martin County didn’t get enough resources from the state to combat the outbreak.

“I do understand the budget constraints that the state is under,” said Ward, who at times picked up rural residents so they could get vaccinated. “We are easy to ignore. … But these people bring so much. They deserve to be rescued.”

He aches for the Ramey family, who he knows well.

On a cold February morning, Stafford, Ramey’s sister, visited the family cemetery in a wooded mountain valley. She stuck cloth flowers into the fresh earth and placed a garden gnome near her brother’s grave.

The 40-year-old followed his father into coal mining and struggled with pills, heroin and meth for much of his life. Years of intravenous drug use had given him hepatitis C.

But his family remembers him as a generous prankster, a 6-foot-2 “brute” who loved car racing, riding his four-wheeler and hanging out with his two teen sons. 

No one in his family had heard of hepatitis A until his girlfriend got it. Then Ramey contracted the virus, and within weeks he was dead.

His family is still angry Kentucky isn’t doing more to save others from the same fate.

“This is very serious, and it needs to be taken more seriously,” Stafford said. “Our people are dying.”

Editor’s note: This story has been updated to reflect newly released state numbers on hepatitis A infections, hospitalizations and deaths.

Brandy Stafford lost her brother James Ramey to complications due to hepatitis A in November of 2018. Michael Clevenger, Louisville Courier Journal

This article was originally published by the Courier Journal in Louisville.

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