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After A Cluster of Rare Cancers, This North Carolina Town Is Looking for Answers: A Q&A with the Author

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Duke Energy's Marshall Steam Station in Sherrills Ford, NC, Feb. 25, 2019. Photo: Kevin J. Beaty

The effects of industry can be seen on the surface of many Appalachia communities, from strip mining in the central coalfields to the new construction of natural gas pipelines, but for decades, people living there have pointed to these and other industries as causing something much deeper, more internal– disease. 

It is not new for researchers to spend years looking at the impact industry is having on the health of a local community in Appalachia, but in some, the connections they find just aren’t clear, and in others, there isn’t enough evidence to even say it exists. 

That’s the case in Huntersville, North Carolina, near Lake Norman, where a small group of people began being diagnosed with some rare cancers several years ago. A number of community members are suspicious that the diseases are linked to pollution from local energy plants, including Duke Energy’s nuclear plant that sits on the lake’s shore, and have demanded environmental testing in the area, but the company, local leaders and outside researchers say that testing would be too difficult– they don’t know where to test or even what they’re testing for. 

Huntersville-native Kevin Beaty, a reporter and photojournalist for Denverite in Denver, Colorado, returned to his hometown to report on the community’s struggle for answers for Southerly. He spoke with 100 Days in Appalachia’s Kristen Uppercue.

KU: You note throughout the story that Huntersville, North Carolina, is your hometown and some of the people who were impacted by cancer in the area were people that you knew growing up. Did you worry at all that your closeness to this story would ever impact your ability to be balanced in your reporting?

KB: It’s definitely something that I kept in mind. But I was actually really excited to do a story about people that I was close with. I mean, Summer Heath is not somebody that I knew, although she went to my high school and her brother played football with my brother, for instance. But we talk a lot about parachute journalism and how it’s something that we want to avoid. We are always sort of striving to make sure that we have the right context to tell stories about communities that we’re not familiar with. And this felt like the polar opposite. And it was really kind of nice [to be] literally going home to talk about it.

KU: Aside from the personal connection, why was this story so important for you to tell to a wider audience?

KB: I left North Carolina in 2013 and at the time, I would not have considered myself a reporter, I was interested in environmental issues, but I’d had no experience in the field. I didn’t go to [journalism] school. I studied film production so I was working on documentaries. But [when I left Huntersville] this issue was sort of beginning to bubble up, that there was sort of these unknown health issues and the community was struggling to have recognition that those were happening. And so I kept a pretty close eye on it. 

I always sort of felt bad that I wasn’t qualified to tackle it journalistically when I lived there. And so when I had the opportunity to produce and publish this piece, it was something that I just felt like I needed to do. So it sort of gets back to that question about being so close to it. This is something that I just didn’t want to fade away. 

KU: Tell me about your research process in a complex story like this. Was it difficult to find the data you needed? Or did you find that a lack thereof was an important part of the story?

KB: A lot of what I reported on in this piece had sort of come to light or had hit the public consciousness throughout the five or more years that this has been an issue for Huntersville. I hadn’t seen them all pulled together into a single sort of narrative to try and bring it together. 

The thyroid cancer issue and the ocular melanoma issue were sort of reported on separately, sort of quick-hit updates. I was really interested in how the communities sort of played off each other and grew. And some of that actually was kind of cut out from the piece. I was personally really interested in sort of the community push to get testing done and how, when the Iredell County group and the Huntersville group sort of realized that each other existed, they bolstered each other’s efforts to do that. 

KU: Lake Norman is manmade and was created by flooding communities, which created a sense of adventure and mystery around it. But that mystery has turned into concern over potentially negative impact to the health of the people living near it. I’m curious if you felt a sense of wonder about the origin story of the lake when you were young. And has that view of the lake changed for you personally into adulthood? 

KB: It’s funny, the lake is one of the only things that I really miss about living in North Carolina. It was a place that I went every weekend. I was constantly jumping fences with my friends to go swimming and fishing so I still have a lot of affection for it. 

I should say that there are no answers to what’s going on here. I found it really interesting that the lake and the town itself [were] really created as a result of these sort of industrial pushes from the ‘20s. And there are a lot of people who don’t know that because it grew so fast. 

There are so many people who have relocated there from other parts of the country and not everyone does their homework and figures out why this lake exists, right? It’s just a place you go boat on the Fourth of July or whatever. 

So, I think there is a sense for a lot of people who live there, including myself, there’s sort of this dual feeling about it, where on one hand, it’s this great feature and on the other hand, people wonder is the industrial activity that’s happening around the lake, having any impact on us? 

Those pieces of infrastructure are things that people drive by all the time. If you go from one town to the next, you will pass by the dam and it’s huge and you can’t miss it. When you’re a kid growing up there, we had nuclear fallout drills, like what do we do if the nuke plant explodes. That’s something that was really present for people who spent some time there. [But] I still want to go jump in the lake at midnight on a hot July night. 

But I mean, people wonder and that’s really the crux of the story. All of these questions are now being raised. I spent a lot of time talking about Duke Energy because they built the lake and because the coal ash issues in North Carolina have sort of made people look in their direction. They’re the biggest player in town.

I’m not saying anyone has any idea why these things are happening. They just asked those questions, and the resistance that people have gotten to getting answers to those questions is potentially more damaging or more interesting than the unsolved mystery at the moment.

KU: As you mentioned, throughout the story, you quote representatives of Duke Energy and even some researchers, as saying it would be incredibly difficult to test the communities around Lake Norman for environmental contamination because they don’t know what they’re testing for or where. At any point, did it seem like that answer was reasonable for the people in the community who are concerned about potential health impacts?

KB: I’d say people are pretty upset that the drumbeat answer that they’re getting is “sorry, we don’t know what to test for and we can’t test for anything.” 

The gentleman, a retired ophthalmologist, who leads the Huntersville ocular melanoma group is basically leading that charge to not test. That committee controls where the money that the state allocates goes and he has said that it would not be scientific for them to just start digging holes and sampling stuff. 

And so people are frustrated. When something like this happens in a town, people start seeing specters and ghosts everywhere. And suddenly, it’s not just, “this is a scientific-method issue,” it becomes “somebody is purposely trying to stop us from knowing the answers.” The way that those rumors sort of spread as a result happens all over the place. An old person in your neighborhood gets lung cancer and suddenly that’s related too, and it’s really hard to sort of balance the demands of the community that are in pain. How do you? How do you find answers? 

It’s unacceptable to some of these people that they don’t know what causes ocular melanoma, and we don’t know what’s in the soil generally, you know, and sorry, but you might have to wait a decade or more for answers. It increases the pain they’re feeling, I’d say.

KU: Concerns of the environmental impacts of industry are common across Appalachian communities that have relied on the energy industry, including coal and natural gas production that we see more commonly today. What can the communities that are attempting to push back against industry learn from what’s happened and is happening in Huntersville?

KB: I quoted a sociologist from Florida in my story and her message was that she studied multiple cases, not just in the south and not just in Appalachia, where communities have tried to get to the bottom of health issues that are related to local industry. Her message was…there’s not usually a happy ending. But she has seen cases where communities have stuck together and were able to find answers. It just seems like it takes a lot of persistence. And it takes using some mechanisms like finding a reporter who wants to talk about the concerns in a community and trying to find state legislators or city council members who will stick to the issue. It’s really easy for these concerns to be downplayed and for the issue to sort of disappear. 

[But] for as persistent as the Huntersville folks have been, they still haven’t gotten environmental testing done and they still don’t have answers. My job is to sort of figure out what they’ve done and try and pull all these disparate pieces together. The Huntersville folks have certainly stayed in regular contact and haven’t given up. 

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A Slow-Motion Emergency: Opioid Distribution Pattern Doesn’t Surprise Author

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Two decades after health officials in Southwest Virginia sounded the alarm about the devastating impact Oxycontin was having on the region, hard numbers confirm that drug manufacturers and distributors carpet-bombed Central Appalachia with the powerful drug and other opioids.

An investigation by the Washington Post shows that pharmaceutical distribution of the opioids oxycodone (the narcotic in Oxycontin) and hydrocodone grew by more than 50 percent from 2006 to 2012. On a per-capita basis, rural Central Appalachia was an outsized target of that distribution.

One person who is not surprised by the findings is journalist Beth Macy, author of Dopesick: Dealers, Doctors and the Drug Company that Addicted America (Little, Brown and Company). Her 2018 book starts with Oxycontin’s arrival in Southwest Virginia in the 1990s and the pleas of healthcare professionals there to the Food and Drug Administration to do something before it was too late.

Macy’s 2018 book has just been released in paperback. A new discussion guide provides some information on what has happened since the hardback version was released last year. In the new section, Macy argues again for greater emphasis on medical treatment for addicts, rather than relying on criminal-court measures to address the epidemic.

We last talked to Macy in January 2019. Now we wanted to get Macy’s reaction to the current spate of state-government lawsuits against Oxycontin manufacturer Purdue Pharma and the new reporting from the Washington Post.

Macy continues to cover opioid addiction. She has a forthcoming article in The Atlantic, and she’s done an Audible documentary about Tess Henry, a central character in Dopesick. The Audible production will be released in October.

Tess, as Macy identifies her in the interview below, became addicted to Oxycontin after a doctor prescribed the powerful painkiller for a routine ailment. Tess’ story follows a familiar path of Oxycontin addicts: from legally prescribed medication, to illegally procured medication, to street drugs like heroin. A 2014 study found that the three-quarters of heroin addicts said the first opioid they used was a prescription drug. Overdose deaths involving heroin climbed more than 600 percent from 2007 to 2017, according to the Centers for Disease Control and Prevention.

Tim: Let me start with a question about the Washington Post and whether you’ve had a chance to look at any of the data. Does it confirm any of the things you spent years reporting on?

Beth: Absolutely. To me, anybody in Central Appalachia would look at that data and would say, “Duh. Duh.” I mean, it was shocking, the numbers. But I wasn’t surprised, at all. I’m surprised by the Washington Post, just now, saying this is a major story. …

Tim: So the issue has not received the attention it deserves?

Beth: I still don’t see the urgency. …

Tim: I think back to how the Purdue criminal case in federal court in Virginia was settled in 2007, relatively early in the whole arc of this story. And, as you say, there was little sense of urgency about their illegal branding the drug so many years ago. It didn’t change things?

Beth: Right. And it’s worse now. And, in fact, Purdue sold even more Oxycontin after that settlement. The U.S. Attorney who prosecuted the case in western Virginia thought that the message from that would be that this drug is always dangerous. He hoped there would have a slowing effect. He didn’t take it off the market. And, in fact, if you go back and you look at those stories about [the 2007 settlement], very few people mention that, “Oh, in fact one of the punishments is that Purdue isn’t going to be able to get business with Medicaid, Medicare, and Tricare as a punishment.” But actually, that punishment was for the holding company, Purdue Frederick, not Purdue Pharma. [So Purdue Pharma could continue to manufacture and sell Oxycontin.

And then, Purdue just simply double-downed on their marketing and they sold even more Oxycontin the next year. And I think a lot of people just thought, “Oh, well we’re done. They picked up a big fine.” Of course, it was really just getting started.

Tim: Do you feel like we’re getting any closer to people understanding what’s at stake and who’s responsible? Is any of that changing with the lawsuits and the criminal complaints on the state level?

Beth: Yeah, I mean there’s so much media about it that I think that there is an understanding of the role that big pharma played in this. I think most people have gotten that message, although still people tell me, “I didn’t know Oxycontin and heroin were related until I read your book, that they were chemical cousins.” But still, there’s a lot of education that needs to be done.

Tim: Your book Dopesick is just coming out in paperback. What has changed since Dopesick was published in 2018?

Beth: Well, I just feel what I hear and see from my own reporting and by going out in the middle of the country now. Things have slowly started to change, while we still need a lot more dollars to put toward treatment. [One estimate is that it’s] going to take $80 to $100 billion to turn this around, and that’s the level of what happened with HIV and AIDS funding. The Trump administration has added like $3 billion. But he said he fixed it. He fixed the opioid crisis. It’s a joke. So there’s a lot more work to be done. And frankly, I don’t think that whatever we get from the opioid lawsuits are going to be anywhere near that amount. But it could make a difference if it’s all handled responsibly.

I have some new reporting coming out in The Atlantic in December about a treatment innovator from Kentucky who’s working in Indiana now and is trying to get the criminal justice system onboard with healthcare to help these folks so they’ll stop this cycling in and out of jail. There are people making some really good innovations now.

We know what works because we’re starting to see reduced deaths in places like Rhode Island, Massachusetts, and Vermont. If you have one person in power who’s willing to step out on a limb and see these people as human beings, and make policy, it can make a huge difference.

In the reader’s guide [to the new paperback edition], I talked about the head of the emergency department at Carilion Roanoke Memorial Hospital. Six hospitals in western Virginia, and how he didn’t believe in MAT [medication-assisted treatment], and didn’t think it was his job, and so they’re basically just NARCAN-ing people [administering NARCAN, naloxone, which treats opioid overdoses] and sending them out into the street with no help at all, no follow up, and can you imagine someone doing that to somebody having a heart attack.

So I heard the head of the emergency department changed his mind, and I called him up and he said, “Yeah, we read your book, and then we looked into the research and we said, ‘how can we not be doing this?’“ So now he’s got 24/7 a doctor in the ER, waivers to prescribe enough buprenorphine [an opioid used to treat withdrawal symptoms] to get them to their bridge appointment with the outpatient provider. And when you ask him how he feels about it he says, “I feel like doing cartwheels every day because we’re having success with it. We’re not seeing the same people over and over.”

When I was in Burlington, Vermont, I saw the same response. In Burlington, the police chief, who supported the mayor and hired an opioid response director, of course, they’re an early Medicaid expansion state. And they realized that out of the 34 overdose deaths, every single person had come into contact with police [before their deaths]. So they decided that they’d de-criminalize heroin and even if you’re selling just to use, they don’t arrest you for that, they actually take you to treatment and the opioid response director sort of oversees it like a social worker. And they talk about every single person, every two weeks in a meeting, and their overdoses went down 50 percent in a year … 50 percent. So we know what works, we’re just not doing it to scale to match the scale of the epidemic.

Tim: You’re out there talking to a lot of different groups and I’m just curious if you can summarize what the response is with these different communities that you’re visiting.

Beth: Well it just depends. We’re such a varied country. When I go to small towns, people would come up after and they’d say, “It’s even worse than you said.” So when I go to a city, there’s always people, … usually sitting in the front row, that are crying because they’ve lost loved ones.

A truck driver in Maine said he had lost 15 people. He’d been in recovery I think two years now. He said he hadn’t been able to cry about any of it until he read about Tess at the end of my book.

[Author Robert Gipe] said he was talking about how Purdue should pay reparations to Appalachia and somebody [in recovery who had read Dopesick] came up to him afterwards … and said, “I didn’t understand that I was part of a bigger story until I read that book. Before I read that book, I thought I was just a f— up.”

Tim: Wow.

Beth: That’s the way I felt too. Because it’s a slow-motion story, and people didn’t get it. Even people who were intimately involved in it. So, I’m grateful for those comments.

One woman reached out to me and she said she was reading the book and her sister had been in recovery for two years and she was getting to the part she thought Tess was going to die, but she didn’t know. And the woman kept saying, “Oh, we’re so lucky, we’re so lucky.” And before she finished the book, her sister relapses, OD’s and dies. She was in Indiana and I was going to be speaking in Ohio the next week or maybe two weeks later, wasn’t long at all, and she and her dad came over to meet me. I still think there’s a huge amount of stigma and that people were suffering are grateful that people are talking about what’s happened and they’re not just seeing these human beings as addicts and criminals and moral failures. They’re seeing that it’s that it’s part of a larger story of greed and putting profits before people.

Tim: Tell me about these other projects you have going.

Beth: I have an audio documentary coming out by Audible on October 3rd (2019), and that is taking Tess’s story and telling it, but in her own words, you hear her. I recorded all our interviews not knowing I was going [to use them in an audio program]. After her death, her mother and I decided to try to retrace her last steps. So we went up to Las Vegas once by ourselves and we went another time with an Audible producer. We found the person who found her body in the dumpster. We found people she had crossed paths with who had helped her. We interviewed the police. We wrote about the homeless addictive community in Las Vegas, which is a lot different than being homeless in Roanoke. It’s really rough out there.

She told her mom she was being gang-stalked. No one in power even would admit that that was a thing, but we interviewed a lot of people who used to be on the street and they told us all about it. We learned a lot about her final days and weeks that were both worse than we thought and, in some ways, better than we thought in that she did have a community out there.

There’s also something that, as a journalist you don’t really get to go back and take a hard, hard look at something such that when I was listening to her, the very first time I interviewed her in 2015 when I’m listening to her with my 2019 ears, I’m saying, “Oh she knew exactly what she needed.” She talked about urgent care for the addicted. That’s what’s happening now at Carilion. Instead of being thrown out into the street, they’re actually treating them now. She was trying so badly to get home, to get on Methadone. Anytime she lost access to her [medicine-assisted treatment] things spiraled downhill. And when you look at it, knowing what we know now, you can see that she knew exactly what she needed.

We’re sad but there’s some happy things at the end of it. Her mother is now raising her son. They talk about Tess every night. “Tess loves you.”

This article was originally published by the Daily Yonder.

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New Prescription: Ohio Valley Native Dr. Patrice Harris Is First Black Woman To Lead AMA

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AMA President Dr. Patrice Harris (center) stands with the immediate past president Dr. Barbara McAneny (left) and president-elect Dr. Susan Bailey. Photo: Courtesy AMA

This article was originally published by Ohio Valley ReSource.

Dr. Patrice Harris took the oath in June to become the first African-American woman to serve as president of the powerful American Medical Association, the largest professional association for physicians in the United States.

Harris also brings another unique perspective to the job as someone who grew up in rural Appalachia.

“I was born and raised in Bluefield, West Virginia, in the heart of coal country,” Harris said. “My father worked on the railroad. My mother taught school. So I have a unique and personal connection and understanding of the region.”

She earned her undergraduate degree in psychology, a master’s degree in counseling psychology and medical degree from West Virginia University. Though she has long practiced psychiatry in Atlanta, Georgia, she keeps her connection to the region with regular home visits and by serving on the WVU Foundation board.

Dr. Patrice Harris is inaugurated as the AMA’s president during a ceremony in June. Photo: Via AMA Facebook Video

Dr. Harris, MD, MA, began serving on the AMA’s board of trustees in 2011 and was nominated to serve as that board’s chair from 2016-2017. She has led the organization’s efforts to combat the opioid epidemic as chair of the Opioid Task Force since its inception in 2011.

She has also served in leadership positions with the American Psychiatric Association, the Georgia Psychiatric Physicians Association, the Medical Association of Georgia and The Big Cities Health Coalition.

Harris was elected last year to lead the AMA.

I recently spoke to her about what the appointment means to her, her ties to the Ohio Valley region, and how she thinks the AMA can help the region face some of the nation’s toughest health challenges.

Breaking Barriers

Aaron Payne: What does it mean to you to be the first African-American woman elected as president of the AMA?

Patrice Harris: It is certainly an honor and a privilege to be the first African-American woman president of the AMA. I know that I can stand as tangible evidence that young girls from communities of color can aspire not only to be physicians but to be elected to the highest office of the physicians of this country.

Payne: What do you think it means to the AMA to have a woman of color as president?

Harris: Being president of the AMA is the culmination of many years of work, dedication and sacrifice. Not just from me, but by those who have been my supporters in the AMA, also my physician colleagues in psychiatry and from Georgia. 

The president is the highest elected office of the AMA and is the primary spokesperson for the policies and the work of the AMA. I believe that the AMA is very proud, again of the work of all of its presidents, those proceeding me, but certainly there is some additional pride I believe in my currently being the first African-American woman to hold this office. 

And not only that, for the first time the AMA will have women as the immediate past president, the president and the president-elect, so that is another wonderful accomplishment that the AMA is celebrating.

Payne: With your connection to the region, what would you say are the most pressing issues specific to here that you feel the AMA can help address?

Harris: The AMA is an organization that sets policy and then advocates for that policy on the federal level and certainly with the partners at the state level, for instance, the West Virginia State Medical Association. 

We definitely highlight the burden, both the human cost and the financial cost of chronic disease. I know that in West Virginia, there is a significant burden for those who have diabetes, who have high blood pressure, those who have an opioid use disorder, so the AMA has strong policy. 

We’ve been advocating for increased funding. We want to make sure we increase understanding that substance use disorder is a brain disorder. It’s a chronic illness just like diabetes and hypertension.

At the AMA, we’re strong supporters of the Affordable Care Act because we wanted to make sure that those who were uninsured or under-insured had access to healthcare. We know that in West Virginia, Kentucky and Ohio there are a significant number of folks who don’t have access to healthcare.

Certainly, the expansion of Medicaid was critical in getting access to healthcare, so that people can go to their physicians and get treatment for their diabetes, and their hypertension, and their opioid use disorder. And get treatment early, so that they don’t feel like they have to wait until the disease has progressed, or that they don’t feel like the only option for care is the emergency department.

Strategic Arcs

Harris’ tenure finds her working to improve the health of patients and improve working conditions for doctors in an interesting time.

The Affordable Care Act, which the AMA supports, is again being debated in a federal appeals court over questions of its legality. The case is likely heading to the U.S. Supreme Court.

Her time will also be spent implementing and advocating for policies that fall under the AMA’s core strategic arcs: attacking dysfunction in the healthcare system, re-imagining medical education and confronting the chronic disease crisis.

Harris: Regarding attacking the dysfunction in healthcare, we know that regulatory burdens, electronic health records are a significant cause of physician dissatisfaction and, unfortunately, burnout in the physician community. The AMA is working on several fronts to address that issue certainly to reduce the amount of paperwork and the regulatory burden. In fact, we did a study several years ago that showed that for every one hour physicians spend in caring for patients we spend two hours in [paperwork and desk work], and so we’re working on many fronts in that area.

We have been working on those areas for some time regarding changing and innovating the way we train the next generation of physicians. We have, over the last several years, awarded grants to medical schools first and now to graduate medical education programs. Those are the residency training programs that we physicians do after we graduate medical school. The AMA has awarded over $30 million dollars in grants to schools and other affiliated institutions to innovate and look at how we can all innovate in training the next generation of physicians. 

When it comes to decreasing the burden of chronic disease, we are working in the areas of pre-diabetes because we are imagining what we can do if we prevent people from getting type 2 diabetes. We are working in the hypertension space. We know that so many of us are walking around with high blood pressure and don’t know it. We’re working with physician practices to develop ways to make sure that folks who have high blood pressure are getting the treatment that they need, and certainly, we know that then prevents later strokes and other health issues.

Of course, as a psychiatrist, I’m highlighting the connection and the importance of incorporating mental health into overall health care, the importance of addressing trauma early on, so that we can prevent a disease burden related to trauma.

And finally, increasing the diversity of the physician workforce and amplifying the AMA’s new work on health equity.

Addiction Policy

The Ohio Valley region has some of the highest fatal drug overdose rates in the nation. It was also considered a “canary in the coal mine” for the epidemic.

Opioid painkillers overprescribed by doctors and shipped in waves to “pill mills” by manufacturers and distributors fueled the addiction crisis in small, rural towns across the area. 

The AMA’s Opioid Task Force that Harris chairs recently released its 2019 Progress Report on the epidemic. It highlights how improving doctor education about opioid painkillers and overprescription contributed to successful reductions. It also offers recommendations the AMA believes can break down barriers to treatment.

Harris: I think it is important to talk about what’s working. We highlight the numbers regarding the decreasing number of opioid prescriptions that are written, around 28 percent nationwide over the last four to five years. Physicians have been enhancing our education on opioid prescribing on pain, and so there is progress.

I do want to say, now we do want to be judicious in our prescribing, but we also don’t want to limit patients who have pain. We don’t want to limit their access to appropriate pain care and opioids do play a role in pain care.

There is an area [that can be improved upon] regarding access to treatment. Across this country, only 2 in 10 people who want opioid use disorder treatment have access to it.

We highlight the fact that there are more physicians and other health professionals who are trained to provide MAT, or medication-assisted treatment. That’s the evidence-based treatment for those who have an opioid use disorder. 

We need to make sure that we vigorously [minimize] regulatory burdens – we call those prior authorizations in our world. I may have to fill out a piece of paper or may have to make several phone calls before a patient can get into treatment. Well, that delay in care could mean death, and so the AMA is highlighting that issue.

We work with several states also to make sure that state insurance commissioners are holding their insurers accountable for parity, making sure that coverage for substance use disorders and other mental disorders is on par, is the same, is at the same level as coverage for other medical illnesses.

Credit: Alexandra Kanik/Ohio Valley ReSource

Our progress report, as you note, highlights the progress that has been made and really points to areas where we need to continue to work. We can work with state regulators, and insurance commissioners and attorneys general to make sure that barriers are eliminated.

Payne: Another recommendation made in the report is to lessen the burden of “step therapy,” where people with a substance use disorder will be required by insurance to try a certain treatment before they can be approved for another. In rural regions like ours where a treatment option may not be available, people are left with traveling miles and miles to get treatment. As advocates, how do you convince people making those decisions to take into account regions like ours?

Harris: The AMA always brings it back to the patient. We have to make sure that the patient is first and that the treatment options are based on what the patient needs, not what an insurance company has decided should be first. We always highlight the need to put the patient first, and take into account where the patient is, and the services available.                  

Regarding location, we need to make sure that services are available. We could use some innovation there. But you’re right, we should be looking at the patient, and the patient population, and the resources in making sure patients get what they need and not what’s on a piece of paper, or in an algorithm or in a step therapy document.

Payne: What do you see as the role of physicians in continuing to combat the opioid epidemic moving forward?

Harris: There are many complicated factors that lead us to where we are today in this opioid epidemic, but what we wanted to do [by forming the Opioid Task Force] was demonstrate physician leadership. You may be aware, our first set of recommendations came out in 2015, and those recommendations were specifically geared towards what physicians could do and it was to sign up for our state database programs.                                       

You may be aware, or your listeners may be aware of the physician drug monitoring programs. Those are the programs where physicians can check to see what other medications, particularly opioids and other medications that might interact negatively with opioids. What other medications our patients are on? We encouraged our physicians to do that.

We encouraged in those first recommendations for physicians to enhance our education…and they did as evidenced by the progress report. Our second set of recommendations, as we discussed earlier, was about what can we all do as a community because physicians alone cannot solve this problem. It requires partnerships with state and federal government. 

Mental Health

Harris plans to use her background as a psychiatrist to advocate for bringing mental health care into the primary health care system.

For rural areas like the Ohio Valley region where mental healthcare facilities can be scarce, this will include making more mental health resources accessible.

Harris believes there are things that can be done to help this process along.

Harris: I am a child and adolescent psychiatrist, so certainly I’ve seen over the course of my career the importance of integrating mental health care into overall health care. For so many years there has been a stigma associated…with having a mental disorder, whether that’s depression, or bipolar, or schizophrenia, or a substance use disorder. Talking about it, elevating it in the conversation, bringing it into our primary care practices, there are many models to do that.

States and practices are using telemedicine, which means seeing patients through the use of computer and working with patients remotely. There are many models working. I believe New Mexico has a Hub and Spoke model, and again, not just for mental health. There is innovation out there.

Actually, I keep in contact with West Virginia University. I serve on the WVU Foundation and I’m back often. I know that in West Virginia they’ve been using, the psychiatry department, has been using telepsychiatry for many years.

Now it’s a matter of funding and making sure that those services are paid for in both our public and private payers. Again, a role that AMA plays in advocacy and of course a state medical association.

Payne: Is there anything you’d like to talk about that I didn’t ask about or anything additionally you’d like to add?

Harris: The only issue we haven’t talked about that I raised in my inaugural address was the need to focus on trauma and childhood trauma, ACES work. It stands for Adverse Child Experience Survey. We know that adults who experienced certain traumatic events in childhood are affected later…by cardiovascular disease, diabetes, heart disease.

The other issue that I just want to highlight, and I think we should talk more about in our country, is childhood trauma and the need to make sure that we have the resources available to address early socio-emotional learning in our children. And when our children have experienced trauma, we need to make sure there are systems in place to support them after they have experienced a trauma.

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Q&A: ProPublica and the Gazette-Mail’s Guide to Every Natural Gas Well in WV

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Screenshot of the imaging tool used by ProPublica in "A Guide to Every Permitted Natural Gas Well in West Virginia." 2019

In West Virginia, natural gas is booming. For landowners, natural gas development on private land previously meant hidden wells in the woods, which may have been a minor nuisance for those on the surface. But the advent of a drilling process called horizontal drilling now allows producers to drill for miles underground in all directions from a single point. In 2006, the state had issued only a dozen total horizontal well permits. As of last year, that total had reached over 5,000, according to data from the state’s Department of Environmental Protection.

In order to build horizontal wells, gas producers must first clear acres of rural landscape, bringing loud and disruptive trucks, machinery and construction to previously calm rural areas. Until 2011, there weren’t many restrictions on where natural gas producers could put well pads. Now, regulations only dictate a 625-foot buffer from homes from the center of the well pad, meaning the large well pads themselves could end up much closer than that to dwellings. This disruptive construction can still happen on public land, near schools, or on private property where landowners don’t have mineral rights, disrupting their quality of life and the utility of the land itself.

In their recent deep-dive into the issue, “A Guide to Every Permitted Natural Gas Well in West Virginia,” ProPublica and the Charleston Gazette-Mail used software to show in detail aerial imagery of as many as 1,500 of these well pads. 100 Days in Appalachia spoke with Gazette-Mail reporter Kate Mishkin and ProPublica news applications developer Al Shaw about the process that went into creating this monumental report, and their hopes and predictions for the future of this industry.

100 Days in Appalachia: Why did you feel like creating this tool was necessary? What information does it provide that people don’t already have access to?

Al Shaw: We did a project at the end of last year called Powerless with the Gazette-Mail about the impacts of gas drilling on residents, and kind of what it’s like living near this kind of development. But that project was super anecdotal, and was really based around a couple individual cases. After doing that, I was kind of left with questions about what the scale was across the state. I just started with that question and went down the rabbit hole in the data that the Department of Environmental Protection (DEP) provides. As I discovered how they did these things I wanted to show and tell people how big they are, and how many of them are there there are. So as I did that, I kind of came across a couple techniques to extract aerial imagery from data and kind of come up with the idea of just showing every single well they had, because they’re all acres wide. The key was showing the cumulative effect of drilling across the state, because that’s how large how large footprint has.

Kate Mishkin: It kind of like, well, we have this anecdotal story, right before the legislature started. So I think the question on my end was, what are people going to do about it? Not a lot, it turns out.

100 DiA: What were some of the challenges of creating such heavily data-driven report?

AS: The DEP data doesn’t have a concept of a well pad in it, it only has the concept of well permits. I learned when I was doing the Powerless story that the data can sometimes be out of date, too. So it’s kind of hard to tell which wells are active, or which was completed, or which wells are in the process of being built. So there’s some data challenges there. I started with just this data set of well permits, and then had to come up with a way of clustering them together to find the pads, because the well pads are really a bunch of wells in a pretty tight location, set up in a cluster. I had to match them in a geospatial database. The next big challenge was trying to figure out how to get the aerial imagery from those clusters. And thankfully, there’s this thing called Google Earth Engine, which is really powerful tool for programmatically processing large amounts of aerial and satellite imagery. One of the data sets they offer is dataset called the USDA NAIP, which is the national agriculture imagery program. It’s this really cool free data set, where they take pretty high resolution images of the entire country every couple years. Using Google Earth Engine, you can tap into anywhere in the country and get a radius around point.  What we did was we we set in all of the points that were the center of these clusters of well permits into Google Earth Engine, and came up with these 1,500 images. And you can kind of see them in all stages of development, because the imagery might be too old to see the development started. Some of them are fully completed, where you can see the roads spider out from them, and you can really see the kind of impact they have on the environment. Each one of these images has a 250 meter radius. So you can really tell how big these developments are—they’re acres wide. And when you compare them to the way gas wells used to look, you see what they look like before horizontal drilling, like they wouldn’t even show up on these images. They’d be the size of a pixel. So the difference in scale is just exponential from what they used to be. And there’s 1,500 of these.

100 DiA: What about this study or its findings surprised you?

KM: I didn’t realize how history just repeated itself. Since these studies. These studies were completed in 2013, but the same bills have been presented over and over every single year, sometimes by the same people. It seems like in some cases, they were kind of handed off onto a different group of lawmakers. Repeatedly, it’s just never been acted on. It’s kind of interesting to talk to some lawmakers who are like, “Oh, yes, I forgot about that,” or, “Oh, yeah, there’s something there, maybe we should act on it.”

AS: It’s interesting how quickly all this happened. In 2008, there weren’t any of these pads. And so in the course of 10 years, the amount of space devoted to to natural gas development in West Virginia has just exploded. Each one, on average, is 2.4 acres now, and that’s about double what they what they were in 2007. It’s just a massive amount of space given up to two gas drilling. And we know that they they don’t produce forever, but that scar will be there forever. There’s not a whole lot of regulation. That was the law that was passed in 2011 which put some restrictions on where you put the pads. But that law didn’t put any restrictions on pads next to schools or other sensitive areas like public land, and so there’s still not a whole lot of restrictions on where you can put these.

100 DiA: Have you talked to people directly affected by having gas wells on their properties? If so, what did they say? Were there any comments that weren’t included in the court cases?

KM:  In the Powerless story that kind of preceded this one, we spoke with a lot of people about some of that information that up in in the record and in court. I think it’s worth noting that these cases are still being played out. One is being heard by the Supreme Court this week. One of the residents said that living near a site is like living next to Mountaineer Field. It’s something that people here probably know very acutely what that looks like. And that’s something that other people may not think.

100 DiA: Lawyers for the Harrison plaintiffs say that this kind of development was never contemplated when mineral rights were sold a century ago. Can you speak more on that?

AS: So when we were reporting the previous story, a lot of the people we talked to, who don’t own the mineral rights told us that they knew natural gas development was going on on their land. For them it didn’t really matter at the time because of how light the footprint was. There might be a well up in the forest somewhere, and someone might come out and check on it now and then, but it really didn’t affect their lives. They could still do their farming, they still have their forests, they could go hiking, and they still you had their water sources. But with the advent of horizontal drilling, all of that kind of changes, because it wasn’t just that well up in the forest that someone comes and looks at every now and then—now it’s putting in a huge road, taking down trees, flattening the hilltop, putting in a gigantic gravel pad, constant truck traffic, constant drilling. It’s a much different process. It’s turning what would be a rural peaceful town into a industrial zone. So I think that’s what some of these plaintiffs are getting at with this idea of the contemplation of the parties that back then—maybe this kind of industrialization of the landscape wasn’t contemplated when they sold mineral rights. There is still this idea of the surface owner being able to use the land for for their needs without completely turning it over to the gas drilling or to whoever owned the mineral rights to do with what they want it.

100 DiA: I was shocked to read that as horizontal drilling technology gets better, well pads are getting bigger. Can you explain more about how developments in this industry could mean harsher effects for those on affected land?

AS: Some surface owners say that the centralized well pads are actually a lighter touch on the environment than having a whole bunch of dispersed well pads, or that they have a lesser effect on individual people, because there’s only one pad rather than pads everywhere. But then that means that there’s kind of a disproportionate impact on the people that are next to those pads. And the impact is cumulative, so it’s pretty much greater. It is a bit of a trade off from lots of vertical wells everywhere to to individual centralized centralized pads. But it is it does have a much bigger footprint and requires much more reconstruction more heavy machinery, and more of kind of all the stuff that comes along with rapid industrialization. And I only expect that’ll get bigger as the technology gets better.

100 DiA: Passed the statistics quoted in the piece, what are your predictions for the long-term impacts of this gas boom on WV’s people? Is another bust approaching?

KM: I think a lot of experts will say that there is a bust coming, and a lot of those jobs are temporary jobs. When we talk about what was like fathomable or contemplated in the past, I wonder what is going to be in the future that I can’t even contemplate right now? Or we’re not thinking about interest as far as construction and energy and stuff like that. I think that I think a lot of people would say that it’s not as rosy as it as the industry maybe wants folks to think it is.

100 DiA: What are your hopes for the future use of this tool? What could be accomplished with it?

AS: I hope that people can use it as a tool to really see what’s going on there. And especially people outside West Virginia that might not know that that’s where their energy is coming from. There’s so much resource development. I’m not super confident because of how captured the legislature and the Supreme Court are right now that much will change, but hopefully it will raise raise awareness and it’ll be a good resource for people in the state to find out where the development is near them. Because a lot of people, even if they live near wells might not know how extensive the development is around them.

100 DiA: What about your call to action—what do you hope to gain from folks reaching out with their experiences?

AS: The call to action to hear more from people affected by this story is something that’s been at the bottom of every Local Reporting Network story that we did last year. And I think it’s already proven to be really helpful because we don’t want to just put something in the newspaper and forget about it. We want to be able to actually talk to the people who are affected and make sure that we’re engaging with these people and these communities. There’s so much to report on, and it’s constantly evolving.

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