Eric Douglas Published

Appalachia’s Health Problems Are America’s Health Problems, New Book Says

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A new book called “Appalachian Health: Culture, Challenges and Capacity” explores major challenges and opportunities for promoting the health and well-being of the people of Appalachia. The book is a collection of essays on various topics, looking at health’s intersection with social, political and economic factors.

Cover - Appalachian Health.jpg


Eric Douglas spoke with Dr. Randy Wykoff, one of the book’s two editors, to get a better understanding of the issues facing Appalachia and how solutions used here can be used to improve the health of the whole country. Wykoff is a founding dean of the College of Public Health and professor in the Department of Health Services Management and Policy at East Tennessee State University.

This interview has been lightly edited for clarity.

Douglas: The word that you used in your book is that Appalachia is not monolithic. But we still do think of Appalachia as a bit of an island, within the middle of the country. Let’s talk about that just for a second. 

Wykoff: Many of the health challenges that face the country are simply more concentrated in Appalachia: poverty, lack of educational achievement, lack of access to health care, poor health behaviors. And there are reasons why that has happened. But I think for me, understanding Appalachia helps you understand the health challenges of Americans everywhere. It’s not that our problems are unique, it’s not that we’re unique, we’re not different, necessarily. But we have this series of health challenges that are worse here. And if we understand and can deal with the health challenges of Appalachia, we can deal with them anywhere.

Douglas: At the beginning of the book, there’s a list of health outcomes, that in the United States as a whole are lower than the rest of the industrialized world. Birth outcomes, injuries and homicides, adolescent pregnancy, things like that. But then you say that in Appalachia, they are even lower. Why do you think that is? Why is it a problem in Appalachia? 

Wykoff: I think the way I think about it is that most of what we see in Appalachia is the result of multiple intergenerational cycles. We know that if you’re born poor, you’re likely to stay poor. We know if your parents are less educated, you’re likely to be less educated. We know if your parents are smokers or obese, you’re more likely to be smokers or obese. And these cycles get worse and worse over time.

In fact, in our country overall, the gap between rich and poor has been widening for over 50 years. So part of what we’re seeing in Appalachia is the outcome of these intergenerational cycles. And I think the reason the U.S. ranks worse than other countries is because we have so much diversity in our health outcomes within the country. We’ve compared central Appalachia to the non-Appalachian counties in the same six states of central Appalachia. They’re less healthy. It’s not a southern phenomenon. It’s an Appalachian phenomenon related to poverty and intergenerational cycles.

Douglas: So what do we do about it?

Wykoff: I think the key is recognizing that there is not one solution. Oftentimes, people say, “Well, if we’ve got a problem with health, we just need to get more providers into the community.” And that’s a real problem. As you know, a lot of Appalachian communities have no health care at all. We’ve seen rural hospitals closing. But the real secret to improving health long term is economic development, jobs, education and changing behavior.

That’s not to say access to health care isn’t important. It’s really important. But we’ve got to recognize that those things are interrelated. Think about it this way, every employer you talk to will tell you they need a healthy, educated, drug-free workforce. Those are so interrelated, that what we’ve got to do really is get those folks that are working on the education side, those folks working on economic development, those folks working on behavior change, get them to work together. That’s really the secret to improving health and Appalachia, in the southeast, in the US/Mexico, border region, everywhere in our country. We talked about canary in the coal mine and to me, Appalachia fills that role. We are a bellwether for health conditions throughout the country. And I guess by extrapolation, if you solve the problems here, it can help in underserved rural, impoverished regions throughout the country. The issues that face Appalachia are not fundamentally different from the issues that face other parts of the country. They’re just more common here.

Douglas: Okay, magic wand time. 

Wykoff: I’m trained as a pediatrician, so I tend to think of issues from the child standpoint. To me, anything we’re going to do in Appalachia, or in tribal lands in the US/Mexico border, or rural America, anywhere is going to have to start with early childhood interventions. You want every mom to get prenatal care. You want every baby born in a safe environment, you want mom to know that baby should go to sleep on the back, that they should breastfeed for six months, they should be in a car seat, someone can be reading to that baby. It’s not rocket science. But we’ve got to change it incrementally. The analogy of turning a great freighter in the ocean is probably the one for us, right? You’re not going to turn on a dime. But if you start turning a little bit in time, we’re gonna see major changes.

Douglas: Why aren’t we making these changes? At the beginning of the book, you alluded to Lyndon Johnson and the War on Poverty. That was 60 years ago, or very close to it. So why haven’t we made these changes? 

Wykoff: The gap between rich and poor in our country has been widening for 60 years. And if you believe as I do that poverty is one of the great predictors of poor health. You just see this gap widening and widening and widening. And you know that poor communities have less money to invest in their school systems, the way taxes are distributed. I mean, it’s multiple cycles that overlap each other. I think we’re starting to see some important improvements. But you know, it’s going to take a while.