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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

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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Appalachian health

Schools, Libraries Are Obvious Setting For Telehealth

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Telehealth services offer fast connections and easy accessibility to community institutions.

With faster connections and easy accessibility, these community institutions are the logical place to offer telehealth services.

When communities design broadband infrastructure to facilitate healthcare and telehealth delivery, they obviously plan to connect medical practitioners’ hospitals, offices and other healthcare facilities. Network connections to homes are growing in importance as government policies and market forces favor telehealth deployments.  

What about schools and libraries? 

In many communities, school districts and libraries outperform broadband in people’s homes. For example, the Federal Communications Commission through it its E-Rate fund gives schools and libraries hundreds of millions of dollars to build higher speed networks. Subsequently, these institutions often have the fastest broadband connections in the community

Logic and need, therefore, seem to dictate that communities consider telehealth delivery in schools and libraries. School administrators and parents prefer that students, teachers and parents spend as little time as possible out of school for sickness or traveling to doctors’ offices. Libraries reach out and touch virtually everyone in their communities across the entire economic spectrum.  

School’s in Session – That’s Where the Need Is 

The flu was a serious challenge for Sevier County School System in Tennessee that resulted in school closings. “In some winters, the flu could affect as many as 20 percent of 14,000 students, causing entire schools to shut down in an effort to slow the spread of the flu,” explained Don Best, coordinator of school health for the system.  

In 2009, the school district turned to telehealth. They use video-conferencing hookups and USB-compatible devices from AMD Global Telemedicine for quick exams and recording vital signs.  

Cherokee Health Systems, an area medical practice, is a key element of the telehealth solution. The county also makes sure there is a nurse for every school to assist with the video consult. This partnership allows students to gain access to a higher level of healthcare than what a school nurse is typically able to provide alone.  

“During the consult, the medical staff can examine the eyes, ears, nose and throat, as well as listen to the lungs and examine the skin,” said Joel Hornberger, Cherokee Health Systems’ chief strateg officer. With parent’s permission, the staff may also treat minor cuts and abrasions, rashes, strep throat, earaches and flu symptoms, and perform certain lab test.  

Cherokee Health Systems bills the telehealth services to an insurance carrier or Tennessee’s Medicaid administrator. For those without insurance, Cherokee provides an affordable sliding-fee scale for the visit and any necessary lab work. The telehealth system enables the school and Cherokee Health to easily track health and illness trends.  

Sevier stays with the local medical provider instead of using a national “chain” of telehealth providers that are popular now. Connecting the provider with the schools could result in extra broadband network expenses as the community beefs up or expands the infrastructure, but a local healthcare provider has advantages. 

“The concern some regulators have is whether a good standard of practice can be achieved for a person with no pre-existing relationship with the provider [medical staff], which is often the case for one of these national outfits,” says Frederick Pilot, principal at Pilot Healthcare Strategies. “Or the provider’s inability to get vital signs and gather other information on a patient’s history.” 

Besides treating illnesses, telehealth can help maintain a healthy student body. 

The U.S. Department of Health and Human Services funds in part a telehealth program that helped more than half of obese fifth through eighth graders in the rural Magazine School District reduced their obesity. The program is hosted by the University of Arkansas for Medical Sciences (UAMS) Center for Distance Health, and includes three other school districts. 

When the program began in 2016, 62 students (39 percent) of the 159 students in the targeted grades were categorized as obese based on body mass indexes (BMI). By the end of the program year, 51 percent of those students had a lower BMI. 

Libraries’ Role in Telehealth Delivery 

Libraries can team up with healthcare providers to offer health and wellness knowledge as well as telehealth applications and services. Similar to private companies that have healthcare providers schedule on-site telehealth services for employees, libraries could explore partnering with innovative medical practices and insurance companies to offer basic services to library patrons. 

Mobile Beacon has a portable wireless solution that works over the Sprint or T-Mobile networks, and serves low-income populations. The company sells small, portable wifi transmitters with 8-12 Mbps speed and no data caps, and their main markets are libraries. The libraries loan these devices to their patrons for any time between several weeks to six or 12 months. The company is planning a trial program where these devices are part of a telehealth program. 

These hotspots and mobile services could fill the gap caused by patrons who don’t have good broadband at their homes, or they can’t afford cellular or broadband services. Surgery patients could borrow a hotspot and telehealth to facilitate recovery and extended home healthcare while the patients get back on their feet. 

People could use the borrowed hotspots for outpatient rehabilitation and save on travel costs. The potential is there for a myriad of short-term telehealth applications. 

In the future, libraries could become telehealth outposts for traveling nurses. There are 25,000 traveling nurses working for over 340 companies in the U.S. These trained and licensed practitioners take short-term assignments in various parts of the country.  

According to a report issued by Island Health, an authority responsible for providing health services to over 760,000 people on the west coast of British Columbia, “Traveling nurses view telehealth as a tool to better serve clients and wish to integrate telehealth into their practice.” 

Surveyed Island Health traveling nurses recommend telehealth be adopted into the following programs: pre and post-operative consultations, breastfeeding assessments, maternal care, pediatric consultations, diabetes group meetings and respiratory care.  

In rural America where libraries are the best game in town for getting broadband, conference rooms could become temporary stations for traveling nurses implementing these and other telehealth programs. Additionally, supplying these nurses with mobile hotspots could increase their versatility and effectiveness within the community. 

Aligning hospitals and healthcare institutions with a community’s schools and libraries into a telehealth center or hub could pay back good dividends. An engineering design team can create a wired and wireless infrastructure that links all three groups into a mini network and add a number of telemedicine applications and services.  

“These would be a great way to aggregate resources, share network capacity, and lower the cost of participants,” says John Windhausen, executive director of the Schools, Health & Libraries Broadband Coalition. “More communities should pursue these types of consortia, especially in rural areas where telehealth can help to mitigate the damage from rural hospital closures.”

This piece is part of a larger series on telehealth services.

This article was originally published by Daily Yonder.

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