If people develop symptoms of a stroke, every minute they wait to get help increases the risk of their deaths.

In Appalachia, where there’s only about 67 doctors per 100,000 citizens, it might take longer to get help in a health emergency, and more people could die because of it.

The mortality rate from strokes per 100,000 people throughout Appalachia was 43.8 from 2008 to 2014, according to a report the Appalachian Regional Commission, or ARC, released earlier this year, whereas it was 38 in non-Appalachian regions in the U.S. That is 14 percent higher than the national average. 

That number is just one in a trend of higher mortality rates and poorer health care availability in Appalachia than in the rest of the country. 

The region’s heart disease mortality rate is 17 percent higher than the national rate. The cancer mortality rate is 10 percent higher. The chronic obstructive pulmonary disease, or COPD, mortality rate is 27 percent higher. The injury mortality rate is 33 percent higher, and the diabetes mortality rate is 11 percent higher. 

“Folks are facing all kinds of social and economic factors that really limit their ability to get good clinical care,” Perry County Health Commissioner Angela DeRolph said. “Whether it's maybe education or maybe employment and income, they may not have the family and social support that you may see in other areas.”

Appalachia’s poor health extends beyond just physical health. The region has one of the highest suicide rates in the country at about 17 percent higher than the national average. In central Appalachia, the suicide rate is 31 percent higher than the national average.

DeRolph said lower incomes can force people to choose between their mental and physical health and providing for their families.

“When it comes to putting food on the table or paying to go to an athletic facility to make sure you keep your weight down, you've got to pick and choose,” DeRolph said.

About 17 percent of households in Appalachia are impoverished, according to that ARC report, compared with the 15.6 percent national average. That equates to more than 4 million impoverished households in the region.

Poverty and poor health go hand in hand, a report by the Institution for Research on Poverty, or IRP, of the University of Madison-Wisconsin found. 

“Research has shown a link between poverty and poor health,” that IRP report reads. “People with more income tend to be healthier and live longer.”

People living below the federal poverty level have a lower life expectancy rate than those living at or above that level, according to that report. That is because of lack of access to health care to both physical and socioeconomic factors, that IRP report states. 

The number of primary care physicians per 100,000 residents is 12 percent lower than the national average, the ARC report found. In Central Appalachia, that number is 33 percent below the national average. 

Additionally, the number of mental health care providers is 35 percent lower than the national average.

Bret Allphin, the development director for the Buckeye Hills Regional Council, a council of governments in Appalachian Ohio including Athens, Hocking, Meigs, Monroe, Morgan, Noble, Perry and Washington counties, said the problem of limited health care access extends into Ohio.

“It can be staggering,” Allphin said in an email. “In 2015, we found there to be an approximately one to 4,000 ratio of primary care physicians to residents in our region, and a one to 8,000 ratio of dentists to residents. It doesn’t get much more limited than that.”

Allphin said although access is limited, the quality of care in Appalachia is not any worse than it is in the rest of the U.S.

“I think there is a misconception that the health care services available in rural areas are second-rate services,” he said in an email. “I feel it’s quite the contrary. The service is excellent. The effort necessary to obtain that service for some citizens provides a challenge that is difficult to overcome.”

Much of the pressure to improve health care often falls to local health commissions. DeRolph has been taking a “grass-roots” approach to health care by getting residents of Perry County involved. She said there’s more to improving public health than simply providing more doctors.

“I really think the first step is to recognize that health care is more than just what happens at a doctor’s office,” DeRolph said. “It's really the places where we live, work and play. We need to make sure that we work to address not only physical and mental, but also our social well-being.”

DeRolph said communication is one of the most difficult aspects of improving health care in rural areas.

“One of the things that we've identified in Perry County is although we're lacking resources, there are a lot of cool things happening, but they're not getting out to the community,” she said. 

Allphin said access to health care and communication could both be addressed with ever-advancing technology. 

“Technology plays a crucial role in the future of rural health care access in Ohio,” Allphin said in an email. “The reality is that healthcare providers cannot afford to build and operate the vast network of healthcare facilities we would need to fully address the need that is present in rural Ohio communities.”

Telemedicine, or the delivery of medical services such as doctor's appointments online, could help alleviate the issue of access and cost of health care, Allphin said.

“Telemedicine, and all the technologies that encompass that concept, will be crucial for rural areas,” Allphin said in an email. “This technology has many benefits. The patient gets quality and timely medical care, long travel times are avoided, patients can receive diagnosis and treatment in a comfortable setting and the overall cost of providing that care is lowered due to reduced overhead costs.”

DeRolph said telemedicine is promising, but low connectivity in rural areas could complicate the delivery of services.

“The problem we have here in Perry County is sometimes poorer connectivity,” DeRolph said. “We just don't have internet services, or not everyone has a computer.”

Internet access can be very limited in southeast Ohio, and many residents in rural counties have to utilize public Wi-Fi to access high speed internet, according to a previous Post report.

Broadband can also be expensive to residents in rural areas. According to that previous report, internet access in Vinton and Meigs counties — where the median household annual incomes are about $40,000 and $37,000, respectively — costs about $45 per month for a 50 to 99 megabits per second download speed. In Fairfield County, where the median household income is about $60,000, the cost per month for 50 to 99 mbps internet is the same as in Vinton and Meigs counties: $45. 

Since some residents don’t have the quality of internet access they would need to video conference with doctors, and many health companies don’t have the financial incentive to move into rural areas, alternatives to conventional telemedicine may be necessary.

DeRolph said the Perry County Health Department would consider setting up a central location where people could come to access specialist care via internet, preventing them from having to drive further to meet with doctors in person.

Telemedicine, as it currently exists, could never fully replace a real doctor, the ARC report stated.

“The growing popularity of telehealth may provide an avenue for generalist physicians to provide more sophisticated services with support from remote specialty consultation,” that report reads. “However, without policy and medical practice changes, rural areas will continue to experience barriers to receiving specialty care.”



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