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How Kentucky Is Failing Its Workers

While most of the Meade County public works crew finished their lunches, Pius “Gene” Hobbs was raking along the edge of the road, oblivious to the dump truck backing quickly towards him.

Unbeknownst to the driver, Hobbs was knocked to the ground and crushed under the truck’s weight. When the truck accelerated forward, Hobbs’ coworker ran him over a second time. He was killed on impact.

The only eyewitness to the December 2016 incident, a bystander named Greg Turner, said that he didn’t hear a backup beeper on the truck as it reversed. Maybe Hobbs hadn’t either.

At the scene, state police concurred: they couldn’t hear the backup beeper. Later that day, after the employees had gone home and the Vine Grove street was quiet, Kentucky’s occupational safety inspector showed up.

He conducted his own test.

Standing next to the truck, with no other equipment running in the area, the inspector said he could hear the backup beeper just fine. Though those conditions bore little resemblance to the scene of Hobbs’ death hours earlier, the inspector ruled the Meade County Road Department had done nothing wrong.

Or, as a supervisor with the state worker safety agency said in an email about Hobbs: he just “zigged when he should have zagged.”

Hobbs’ widow, Lisa, got a copy of that email.

“We know that’s not the truth,” said Lisa Hobbs. “It just tears you up. You don’t know what to do.”

Kentucky is one of 28 states or territories that runs its own worker safety program, called Kentucky Occupational Safety and Health (KY OSH). When workers die on the job, KY OSH inspectors are charged with investigating the circumstances of the death, and determining whether an employer was complying with state safety and health standards.

But the state agency tasked with protecting workers failed to properly investigate nearly every single worksite death in two years, according to a federal investigation and analysis by the Kentucky Center for Investigative Reporting.

The flaws showed up in almost all of the 44 fatalities examined by federal OSHA in fiscal years 2016 and 2017.

The federal report issued this year focused on Kentucky’s fatality inspections, and found that inspector interviews were “inadequate”; hazardous safety conditions, including those related to a worker’s death, were not addressed; and the sloppy investigations left workers “continuously exposed to serious hazards that remain unabated.”

The federal investigators sought to retrace state inspectors’ steps to evaluate the quality of fatality investigations. But they found a lack of information that made it impossible to know, in many cases, what caused a death or if a company should have been deemed responsible.

The Labor Cabinet, which runs KY OSH, declined an interview for this story through a spokesperson. Gov. Matt Bevin’s office did not respond to repeated requests for comment. Michael Donta, a former Labor Cabinet deputy commissioner who oversaw KY OSH during the time frame reviewed by KyCIR, said in an interview that the findings were “concerning.”

Donta said he had trusted the people working under him, but in retrospect, realized he should have been watching more closely. There’s no excuse for a bad investigation, he said, but it’s hard to expect a struggling agency — underfunded, with high staff turnover and what he felt was a lack of political support from the state — to get it right all the time.

“The investigation, whether it’s a good investigation or a bad investigation, is not going to fix what [families] want fixed and that’s their loved one back,” he said. “Let’s fix what happened and prevent it from happening again.”

What Lisa Hobbs wanted was for the state to do its job, and hold her husband’s employer to account.

“That’s who we were relying on to set everything straight, but that didn’t happen,” Hobbs said. “You’d think [KY OSH] knows what they’re doing, but they don’t have a clue.”

Federal Intervention Looming

The problems in Kentucky’s state-led worker safety program are well-known to the federal government.

In August, the federal Occupational Safety and Health Administration quietly issued a scathing audit known as the Federal Audit and Management Evaluation (FAME) report. In it, federal OSHA identified more shortcomings in Kentucky’s system than any of the 28 other states and territories that run their own worker safety program.

The federal agency criticized the state for only investigating complaints that come from employees of a company — which means 70 percent of the complaints they receive are ignored, because they came from non-employees. Overall, OSHA found, Kentucky is inspecting fewer workplaces than it ever has; the 787 inspections it conducted in fiscal year 2017 was the lowest number in at least a decade.

When KY OSH does inspect workplaces, they’re identifying fewer hazards than in previous years, and the time inspectors take to close a case exceeds federal standards, according to the federal audit.

Federal OSHA also took the unusual step of conducting a special study of Kentucky’s handling of worker fatalities, prompted by a spike in complaints from families and national advocates about KY OSH.

In nearly all of the 44 cases it reviewed, the report found fundamental deficiencies. The flaws included failing to identify the cause of the accident, not conducting or documenting interviews and overlooking obvious violations.

The federal Department of Labor, which oversees OSHA, declined an interview request.

A spokesperson said in a statement that “OSHA is currently in the process of working with the Kentucky Labor Cabinet to craft a corrective action plan that addresses the findings” identified in the report.

Although the state Labor Cabinet refused to make Acting Secretary David Dickerson or a representative of KY OSH available for an interview, its response to the federal audit sheds light on its defense.

The cabinet acknowledged it’s implementing some changes, particularly around documenting interviews. But the cabinet rejected some of the findings outright and defended its investigations.

Federal OSHA pointed out that Kentucky didn’t identify an incident’s cause in nearly half of the cases, and directed KY OSH to develop a strategy to ensure more thorough investigations in the future.

In its response, the Labor Cabinet disagreed. It acknowledged that inspectors are ordered in the agency’s manual to make “every reasonable effort” to determine the cause of the accident, but said that didn’t mean it was required.

Federal OSHA can take over state-run programs like Kentucky’s if they aren’t “at least as effective” as the national standards, but Jordan Barab, Deputy Assistant Secretary of Labor for Occupational Safety and Health during the Obama administration, said that’s unlikely. There are interim steps that federal OSHA could take, though, like withholding federal funds or taking over parts of the state program.

“Having a state program is a privilege, not a right of the state,” said Barab. “It requires the states to address rapidly and seriously any problems that are identified by federal OSHA.”

‘Essentially, it was the worker’s fault’

The federal audit didn’t name the workers or companies involved with fatalities. But KyCIR obtained 47 case files from the state’s fatality investigations for fiscal year 2016 and 2017, including three cases that weren’t included in the federal audit.

Our analysis confirmed the federal agency’s findings: few interviews were conducted, and inspectors often closed the case without determining what caused the fatal accident. The majority of the companies that were issued safety violations and financial penalties, meant to serve as a deterrent, saw their fines cut by at least half.

In Gene Hobbs’ case, no violations or fines were issued.

Meade County Judge-Executive Gerry Lynn called the death a “tragic accident,” and said the county was cleared of all wrongdoing.

But records show there were serious shortcomings in the KY OSH investigation.

The inspector never interviewed Turner, the sole eyewitness. He got no signed employee statements. His accounting of what Hobbs was doing at the time of his death — the inspector said he was walking back from lunch, not raking — contradicts what the state police reported.

Other cases show similar flaws:

A passing vehicle fatally struck Titus Morris and injured another employee while they were conducting road work in Scottsville in December 2015 for the Kentucky Transportation Cabinet.

The KY OSH inspector left the agency in the middle of the investigation, and witnesses weren’t interviewed for four months. Records indicate that the driver of the car involved in the accident was never interviewed.

Because she showed up after the vehicles had been removed, and the employees hadn’t done a daily safety check, the inspector said she couldn’t figure out from available documents whether the crew was using proper safety precautions. But she said she had no reason to believe they weren’t. No violations were issued.

Transportation Cabinet spokesperson Naitore Djigbenou said she didn’t know anything about a daily safety check in this incident, but said the cabinet requires all of its employees to comply with all safety rules.

“It was a very, very tragic event that was really unforeseen and truly an accident,” said Djigbenou.

In Louisville, Jeffrey Burke was crushed to death when the jacks failed while he was working on a car in September 2016. This wasn’t part of his job as a hotel maintenance worker at a Louisville hotel — Burke’s manager ordered him to work on his daughter’s car, records show.

The KY OSH inspector didn’t interview the manager who ordered the work, who was fired by the hotel. He nonetheless decided the manager couldn’t be responsible for the safety violations, since he wasn’t on site at the time.

KY OSH “determined that essentially, it was the worker’s fault,” according to the federal report, and despite possible worker safety violations, it appeared “the state is just taking managements’ word.”

Penalty Reductions ‘Without Any Justification’

In August 2016, Ervin Bledsoe was doing building restoration work for BJB Architectural Metal in downtown Louisville when he fell from a ladder. He ruptured his spleen and died the next day at the hospital. A BJB representative didn’t return a call for comment.

The federal audit pointed out that KY OSH missed possible citations for a lack of ladder training; improper ladder use; and lack of management oversight. KY OSH didn’t ultimately issue any violations or fines. But, the agency had already offered the company a 25 percent “good faith” discount on fines before an inspector began investigating.

More than 90 percent of companies investigated after a fatality in fiscal year 2016 and 2017 were offered a reduction on fines even before KY OSH decided whether violations occurred, according to KyCIR’s analysis. The federal audit concluded these reductions are often handed out without justification.

More than 60 percent of companies that had a fatality received a good faith reduction, which was also concerning to the authors of the federal audit: a fatality “indicates a complete lack of an effective safety and health program, and/or at least a failure in the program.”

One of those penalty reductions was handed out in direct violation of Labor Cabinet rules after 66-year-old Sally Berry was stabbed to death.

Berry was working in a residential care facility in Elizabethtown owned by Louisville-based ResCare, now called BrightSpring Health Services. According to court records, Berry was killed by a resident she was supervising on the evening of January 3, 2017.

The resident was indicted for murder, but the charges were dismissed by the prosecutor on competency grounds, court records show.

The KY OSH report noted that Berry may have been verbally abusive towards the residents. KY OSH issued no citations related to Berry’s death, in part because, the inspector wrote, he “can’t determine if the attack wasn’t provoked.” KY OSH did issue a list of ideas to improve worker safety at the home, but noted these are “merely suggestions.”

Excerpt from KY OSH’s Berry investigation

While investigating, though, KY OSH issued a violation to the company for willfully failing to maintain required workplace injury records. It was the only time KY OSH issued a serious willful violation in the 2016 and 2017 fiscal years.

The company was given a 15 percent reduction based on “good faith,” which KY OSH issues to companies with an effective, written safety and health program.

But KY OSH’s manual says that “good faith” reductions cannot be assessed when the company has any willful violations, since the employer can’t willfully disregard safety regulations and be in good faith at the same time.

And even though the inspector documented at least 10 incidents of workplace violence in two years at the facility and cited ResCare for faulty record keeping, KY OSH handed out an additional 10 percent reduction on the strength of the company’s worker safety history.

KY OSH issued a $14,750 fine to the company after the penalty reductions, according to records.

In a statement, a spokesperson for BrightSpring, formerly ResCare, said, “We remain deeply saddened by this very tragic loss of an employee … We continuously strive to seek prevention-focused safety and quality improvements to ensure the welfare of our employees and the people we support.”

That company paid its fine in full. But many companies don’t.

One in three companies penalized after a fatality saw further reductions after an informal settlement meeting with KY OSH.

These informal settlements are intended to encourage the companies to invest in safety, according to Mike Dixon, commissioner of the department that oversaw KY OSH, then called Office of Occupational Safety and Health during the Beshear administration.

“Whether that’s buying fall protection or paying for extra training for their employees, if they would show proof that they had done that, we would reduce the penalties,” Dixon said. “We felt that promoted safety on the job site more than some little penalty.”

For nearly half the companies that had violations, KY OSH agreed the company fixed the problems during the course of the investigation. Beyond that, KY OSH typically doesn’t follow up in person after a company reports that it has addressed the problem.

Dixon said the department is abdicating its responsibility if its no longer leveraging penalty reductions to fix worker safety violations.

“A fatality on a job site, a vast majority of the time, it could have or should have been prevented,” he said. “Unfortunately, in a poor state like Kentucky, people are willing to do about anything to have a job.”

That’s why, Dixon said, employees need a strong worker safety agency looking after them.

Education Before Enforcement

In public statements, Labor Cabinet leaders have highlighted the focus of the state’s worker safety agency.

Enforcement is not the priority.

“We are going to educate, we’re going to educate, we’re going to educate and we’re going to educate, and then citate,” then-Labor Secretary Derrick Ramsey told WKMS, the public radio station in Murray, in April. “Our team is doing an incredible job of getting out and educating people.”

KY OSH will come and assess a company’s safety program, for free, without the threat of fines or punishment. In 2016, the education division of KY OSH gave voluntary consultations to 334 businesses and offered training to approximately 4,400 employees, according to state reports.

The education program helps businesses proactively identify and fix worker safety violations.

“Last year, we saved in penalties for businesses over $12.5 million,” Ramsey said, naming his agency’s estimate of the penalties that were avoided by education. “When someone can say we’re creating an unsafe environment, I don’t know where they’re talking about, because I can say, the commonwealth has never been as safe as it is now.”

Kentucky remains above the national average on workplace injuries and illnesses. But those numbers are declining, statistics that Ramsey cites as proof that education is working.

The number of fatalities investigated by KY OSH has remained largely stable over the last decade, hovering between 20 and 30 workplace deaths a year. While the 20 fatalities in 2017 was the lowest number in a decade, the year before was among the highest at 27.

Laura Stock, the director of the Labor Occupational Health Program at the University of California at Berkeley, said an opt-in, voluntary education program isn’t a long-term fix.

“Without a really strong enforcement unit … these voluntary compliance assistance programs are not going to be able to do the job,” Stock said.

Though his education-first initiatives continue, Ramsey left the Labor Cabinet in May to head up the Kentucky Education and Workforce Development Cabinet.

Ramsey took a lot of Labor Cabinet senior staff with him, including the commissioner and deputy commissioner of the Department of Workplace Standards, which oversees KY OSH. Ramsey was replaced with an acting secretary.

Donta, the former deputy commissioner, was fired in December. (In a whistleblower lawsuit he filed against the cabinet, Donta alleges the termination was a result of reporting a fellow supervisor’s alleged sexual harassment.)

KY OSH itself has had four different directors of compliance since Bevin was inaugurated in 2015.

That turnover mirrors what’s happening at KY OSH’s lower levels as well. A quarter of all compliance officers have less than one year experience, while 63 percent have three years or less.

Agency leaders have blamed turnover for some of the institutional problems detailed by the federal audit.

“They have a problem at the cabinet with inexperienced investigators,” said Donta. “And because of that, sometimes, things fall through the cracks.”

These employees investigate grisly deaths and dismemberments. They deal with heartbroken families and contentious companies. Entry-level pay for the job, which requires a college degree, starts at $30,000 a year.

According to a state database, even the most experienced officers make about $55,000.

And a little experience working for the state can translate to double or triple the state salary in the private sector.

Donta said inexperienced compliance officers often have to train the next class; compliance officers quit in the middle of investigations; and many work a second job to make ends meet.

This is a problem every state grapples with, said Barab, the Obama-era OSHA director.

“It doesn’t excuse the states from their obligations under the law,” said Barab. “And it certainly doesn’t excuse the states from recognizing those problems and working to improve those problems.”

Experts and former employees agree that to hire, train and retain inspectors, KY OSH would need more money. Funding levels have increased slightly over the last few years, but federal budget cuts to OSHA haven’t helped.

Even though state plans are only required to match federal funds, Kentucky already contributes twice as much as the feds do.

At Hobbs Home, Fight Continues

Lisa Hobbs’s table is covered with documents and articles relating to her husband and his death. Gene Hobbs was run over by a coworker on a construction site in December 2016. Photo by Michelle Hanks

In the basement of the house at “Camp Pius,” the farm that has been in her husband’s family for generations, Lisa Hobbs has a table. It’s covered in neat piles of documents, tabbed and highlighted, laying out everything that has happened since her husband was run over in December 2015.

There’s the obituary, the commendation the county awarded him posthumously, the police report. She kept meticulous track of the dates and documents, injustices and victories.

In May 2018, one of those victories came in the form of a federal report. She had filed a complaint with federal OSHA, alleging that KY OSH had mishandled the investigation into her husband’s death. This was the response from the federal office in Nashville.

Greg Turner, the only eyewitness to the incident, was finally interviewed by a federal inspector. Had that interview been conducted at the time, OSHA area director Bill Cochran wrote, it “would likely have changed the outcome of this investigation.”

Cochran declined an interview request through a spokesman. His report identified multiple possible violations against Meade County, including training violations, management inspection violations and a sweeping violation for failing its duty to protect employees.

And as for that backup beeper, which the police and Turner agreed wasn’t audible, the federal inspector found KY OSH didn’t do enough to verify whether it worked or not.

“KY OSH should ensure that all available evidence is obtained and used to determine the facts at the time of the incident before developing conclusions and findings,” the report reads.

Reading that report felt like a win for Lisa Hobbs. But in many ways, it’s too little, too late.

On June 14th, what would have been her 43rd wedding anniversary, Lisa Hobbs stood in her front yard. She watched the same public works dump truck that killed her husband barrel down her country road. She listened closely as the truck reversed, and began to back down the street.

“No damn beeper,” she said, shaking her head.

More than a year and a half after Gene Hobbs was run over at work, she still couldn’t hear the backup beeper on the dump truck. KY OSH never told the county to fix it.

Correction: Bill Cochran is OSHA area director. A previous version of this story had an incorrect title.

Jeff Young, Jacob Ryan and Emma Collins contributed to this story. Eleanor Klibanoff can be reached at eklibanoff@kycir.org and (502) 814.6544.

Hogwash: Farmers Fear Trump Trade Disputes Are Damaging Ag Markets

Jimmy Tosh sells a lot of pigs. He is owner and CEO of Tosh Farms, Tosh Pork, and Bacon By Gosh, in Henry County, Tennessee, and has 84 contracted barns in the region where farmers grow pigs for his products.

On a recent July day, Tosh craned over some 1,200 piglets and reflected on how recent market disturbances have affected his business.

“These pigs in January were selling for the $75 to $80 dollar mark,” Tosh said. “Because of seasonality and the effect of the tariffs these pigs now are in the $16 to $18 dollar range.”

These little piggies will grow to be around 280 pounds before they head to the market. But with 25 percent of his pork products depending on export markets, the growing trade war between the U.S. and China could have Tosh looking to find the pigs new homes.

With hog prices dropping, will these little piggies go to market?

“China is our fourth largest market by value, it’s our third by tonnage,” he said. “They take a lot of the pork that we do not consume in this country; the heads, the feet, livers and stuff. That market has gone from a thousand metric tons three months ago to zero last month.”

Other tariffs are also having an effect. As with any successful business, Tosh has plans to expand with a new unit that would produce about 225,000 pigs a year. He needs another 40 barns to do that. With the steel and aluminum tariffs in place, the extra costs for metals used in construction will increase his costs by $15,000 and $17,000 for each new barn.

“Whether we build another unit after that really depends on the market conditions we are in,” Tosh explained. “The tariffs, the amount of hogs, and mainly are we going to be profitable or are we going to lose money?”

This week the administration moved to impose tariffs on an additional $200 billion worth of Chinese products on top of the $34 billion in goods already targeted for import taxes. China has already retaliated against that earlier round of tariffs, and other trading partners from the E.U. to the Americas have all put U.S. agricultural products in the crosshairs again.

The National Pork Producers Council reports that U.S. producers face punitive tariffs on 40 percent of total American pork exports to China and Mexico, and hog, corn and soybean farmers all fear they could be losing major customers for their exports.

Farm country is closely aligned with Trump country. But as the Trump administration escalates its trade dispute with China, farmers are among the first to feel the pain.

Soy Price Plunge

The situation is just as dire for U.S. soybean farmers who are losing contracts with China.

In far west Kentucky, corn and soybean farmer Jacob Goodman has just checked the afternoon market prices.

Soybean farmer Jacob Goodman watches prices for his crop drop

“Here is our electronic grains overview,” he said, tapping at a keyboard. Soybeans that had been trading at more than $10 at the beginning of the month were now down to under $9.

“That is the price per bushel and when you are looking at thousands of bushels, gosh, at 60 or more an acre, that price adds up very quickly,” Goodman said.

Soybeans are the top agriculture export for the U.S. and China is the top buyer. The commodity’s price dropped to a 10-year low after China announced its retaliatory efforts. In 2017 more than half of the soybeans grown in the Ohio Valley and the U.S. went to China. Goodman said farmers are already dealing with a near 50 percent loss in profit over the last few years.

“When you go and start picking fights with people that buy your products, that adds a whole ‘nother level to it,” Goodman said.

Countries responding to tariffs implemented by President Trump have said they will retaliate by hitting his base of supporters hardest, farm country. That carries a cruel irony for Goodman. He said he is a blue dot in a sea of red.

“I would definitely say that I am kind of the black sheep in the area because I didn’t vote Trump,” he said.

“Whenever we start to threaten other countries with withholding grain or something like that they just turn around and buy from somebody else,” Goodman said. “A soybean in Kentucky is the same as a soybean in Brazil.”

Goodman’s family farms 4,000 acres of corn and soybeans in Fulton Co., KY.

‘Domino Effect’

The President’s attempt to bring down the U.S. trade deficit has instead increased tension with trading partners, according to David Laborde with International Food Policy Research Institute.

“This is why policy makers are very careful not to play short-term games because there is long-term cost,” Laborde said.

Laborde said there is now a “big premium” for Brazilian soybeans and it is forcing U.S. farmers to have to sell for less in order to compensate for tariff effects.

“We are going to see countries like China aim to diversify their supply chain and start to do new investments or build new trade relations with other countries around the world,” Laborde said. “You know you create a distortion, you create a conflict and policies and markets are going to react all over the world and with a very different pattern of production at the end.”

He said U.S. farmers are simply not in position to absorb these prices with the consecutive annual losses in farm income. “We are in a place where people can go bankrupt if the low prices remain,” he said.

When soybeans became the number one export commodity, many farmers prepared for an increase in demand by buying more land and seed. Those farmers will be the ones with the most to lose in the market distortions brought on by a trade dispute, according to Laborde.

“In the end someone still has to pay for this,” Laborde explained. “So it means that insurance premiums will have to go up and because [the U.S.] is heavily subsidized, the government will have to find money to compensate the insurance to pay the subsidies of the insurance schemes.”

Bargaining Power

Laborde said that all the trade decisions are now coming from the executive branch of government.

“I think there is a lot of bargaining power from Congress that is not used, so maybe they don’t want to enter into a conflict before the midterm election,” Laborde said. “Just two months of this kind of trade war activity can move investors in another direction for two decades.”

But it is not yet clear if the trade troubles will move the President’s base of support.

Farm groups have kept a soft tone as Trump has pushed for new deals, including his attempts at renegotiating the North American Free Trade Agreement. Eddie Melton, an official with the Kentucky Farm Bureau, reflects the majority of farmers in the Ohio Valley who view the President’s actions as necessary.

“There have always been challenges in agriculture–always,” Melton said. “But through challenges we always find opportunities and I hope we can find opportunities again.”

Melton is hopeful. He said if China isn’t willing to move in the direction the President wishes, maybe India will.

“I think this gives us an opportunity to expand markets,” Melton said. “I really do.”

Hog farmer Jimmy Tosh is not so sure. “I don’t support his tariff position. I have always been a free trader,” he said. “I’ve been Republican my whole life but I do have concerns right now,” Tosh said.

National Academy Mining Health Study Disbanded

A federal study that was examining the health impacts of mountaintop removal coal mining — halted last fall by the Trump Administration — is officially over.

The National Academy of Sciences disbanded the 11-person committee of scientists and experts assembled to work on the study.

The committee was about five months into its research when the U.S. Department of the Interior pulled its $1 million grant last August.

The two-year study was to address concerns state officials and some residents of Appalachia had about research that linked mountaintop removal to a variety of health problems.

Interior’s Office of Surface Mining Reclamation and Enforcement approached the prestigious National Academies in 2016. The agency later announced it was reviewing all major grants, including the study, and the committee halted its work.

Paul Locke, associate professor at Johns Hopkins University in Baltimore, chaired the study’s committee. He said the group was deep into the process when the Department of Interior pulled its support and never reconvened.

“I think we were making excellent progress, and I believe if we had been allowed to finish the study we would have come up with some information that would have been valuable to states and the citizens, but, we, of course, weren’t allowed to get that far,” he said.

The National Academies pursued private funding to keep the effort going, but was unsuccessful. Without additional money, the study’s committee was released earlier this year.

Rural Risk: Fighting Disease Amid The Opioid Crisis

Health officials in the Ohio Valley are investigating outbreaks of disease associated with needle drug use in what is emerging as a new public health threat from the region’s profound opioid addiction crisis.

In northern Kentucky the health department is tracking a cluster of 43 recent HIV cases, about half of which are related to needle drug use. In West Virginia, the Centers for Disease Control and Prevention just released a report on 40 new HIV cases diagnosed in 2017 in 15 mostly rural counties.

When CDC researchers looked for the country’s places most at risk for outbreaks of needle-borne diseases such as HIV and Hepatitis C, they found them in Kentucky, Ohio and West Virginia. The 2016 analysis found nearly a hundred counties in the Ohio Valley at high risk.

Health officials say the stigma associated with HIV can add to that risk. In rural communities, stigma can hinder monitoring, testing, and treatment and add to the risk of widespread outbreaks.

The stories of two rural West Virginia residents living with HIV show how powerful stigma can be and what it takes to overcome it.

Carl’s Story

Carl was in his senior year at Concord University in Mercer County, West Virginia, when he had some routine blood work done during a hospital admission.

“They found out that I was infected with HIV,” he said.

He thinks he contracted the disease from a same-sex partner. Even though he used protection, he said, his partner was careless one time.

In this story we use just Carl’s first name. He said it’s been a struggle telling people he has HIV because of the stigma against people with the disease.

“I have two people out of my entire family that know.”

Condoms and “shooting caps” available at a syringe service location

Even, among some doctors, Carl said, he encounters homophobia. He recalled an early visit to a doctor in nearby Beckley.

“She, in so many words said, ‘Well if I were you I wouldn’t have done the actions to get this,’” he remembered. “And that sent me spiraling, that a medical professional would be so crass to somebody that was so mentally fragile.”

At the time, Carl had just been diagnosed. He stopped taking his medication for a few days and almost gave up. Then he contacted the Ryan White program at Charleston Area Medical Center, where he now makes the two-hour round trip drive for check-up visits.

“Word Travels”

Tania Basta, who chairs the Department of Social and Public Health at Ohio University, has done research on the effects of stigma in rural Appalachia.

“There are providers who, in rural areas, unfortunately are still stigmatizing against their patients,” she said. “They may feel that, unfortunately, some people with HIV, they did this to themselves.”

Ohio University health researcher Tania Basta.

Like most places in central Appalachia, West Virginia does not have a high number of people with HIV or AIDS. At the end of 2016 the state health department recorded 1,746 people in West Virginia who were living with HIV.

But researchers like Basta worry about undiagnosed cases, especially in the rural areas of the state affected by the opioid crisis.

“Testing is an issue,” she said. “And I’m not saying that stigma is any higher in rural areas. It’s just that, because of the nature of living in small towns, where everybody kind of knows everybody, word travels quickly.”

The CDC report on the recent outbreak in West Virginia listed other factors contributing to the spread of disease: transportation from remote areas, poor health literacy, and stigma.

The new cases included both sexual transmission and needle drug use. Fourteen of the 15 counties where new cases were identified were on the CDC’s 2016 list of counties at high risk of disease. Yet only three of the counties had syringe service programs, which medical evidence shows is an effective way to reduce harm from drug use. Syringe services, also known as needle exchanges, can also serve as an opportunity to test for needle-borne disease.

Elena’s Story

Few people living with HIV or AIDS in southern West Virginia are willing to tell their stories in public. Elena Imes is one of them. She has lived with the disease for 18 years.

For many years before the disease progressed, Imes said, she did not know she had been infected by her husband. She worries that there are many undiagnosed cases in her community.

“Part of the problem is, the negativity of the disease itself, and the fear, and the stereotyping,” she said. People she meets often assume that “if you’ve got AIDS, you’ve probably did something bad, Christianly bad.”

And she sees that affecting people’s willingness to learn their HIV status

“They don’t want anyone to see them go take a test. Consequently, people don’t take the test.”

Imes has told her story to the media several times, but speaking out has brought some backlash. She recounted one incident from a few years ago, when she worked at a local Walmart.

Elena Imes at a World Aids Day event she organized

A woman recognized her from a TV news story.

“I know you, you’re from the TV, you’re killing us all!” Imes remembered the woman shouting in the parking lot, drawing a crowd. She accused Imes of infecting people by touching things when she stocked the shelves.

“That hurt so bad,” Imes said, tears welling up at the memory. “And that woman really thought she was warning everybody.”

Imes has had other experiences like this over the years. Another woman in her neighborhood was worried Imes could infect people by swimming at the local pool. So Imes stopped going there to swim.

But it hasn’t all been bad. She has neighbors and church friends who’ve been supportive and who check on her. She has four adopted sons, all grown, who stop by sometimes. But for the most part, she has no family to lean on.

Imes lives in a small wooden house in Coal City in Raleigh County, where she runs a small animal rescue service. As we step through the front door, pink curtains and a thin layer of frayed plastic cover holes in her windows. When I visited she wore five layers of clothes indoors to keep warm.

She weighs less than 80 pounds. Her health is deteriorating and she’s struggling to get by.

“Financially, I’m in ruin.”

She doesn’t work at Walmart anymore. A few years ago, she lost her mode of transportation. One night, she tried to hitchhike to work, and was raped. Her perpetrators were never caught. Now, she worries that those who raped her are unintentionally spreading the disease.

Staying Put

As I listened to Imes tell her story, and Carl, I wondered why they stay where they are.

Imes said one reason is because she wants to stay and help other people who have the same disease.

“I would tell them the worst thing they could do is to keep it a secret,” she said. “If you can toughen up, you need to share it, be open about it. That’s the problem, if more people were open then the stigma wouldn’t be there.”

Because she’s been in the media telling her story Imes has become almost a one-woman support system for people here who have HIV. That’s something Carl said people need more of.

“The biggest fear that someone with this has this infection has is doing it alone,” he said. “And that often causes you to become depressed because you are lonely.”

I asked Carl if he’s ever considered moving to a bigger city, where he’d have access to medical treatment closer to home, and where he wouldn’t have to feel shame at his church, or at his local pharmacy.

“I would rather live here and put up a front then move somewhere and be myself,” he said. “I know that sounds kind of odd, but I do love this place. It is a beautiful place.”

Although he is worried that this article will lead his friends and family to find out he has HIV, Carl said he thinks it’s worth the risk. Telling his story might help someone decide to get tested.

Ohio Valley ReSource reporter Aaron Payne contributed to this report.

Trump’s First Year Leaves Obamacare on Life Support in Ohio Valley

Remember the American Health Care Act, the Better Care Reconciliation Act, or the Obamacare Repeal and Reconciliation Act? They were among the many Congressional proposals to end the Affordable Care Act, also known as Obamacare.

If 2017 was the year of endless Obamacare debates, 2018 could be the year when we see the effects on people who need health care the most. Some health experts in the Ohio Valley are concerned that the “forgotten” folks in rural America could lose access to basic health care as efforts continue to weaken the Affordable Care Act.

In May, not quite half way through his first year in office, President Donald Trump used the backdrop of the White House Rose Garden to declare Obamacare dead.

“This is, make no mistake, this is a repeal and replace of Obamacare, make no mistake about it,” he said, flanked by cheering lawmakers.

Republican lawmakers were all smiles at a Rose Garden event with President Trump.

But reports of Obamacare’s demise were premature.

The bill Trump referred to at that White House event was the American Health Care Act. The nonpartisan Congressional Budget Office found 23 million people would become uninsured under the plan, sparking an outcry at town hall events around the country, even in Trump strongholds in Kentucky, Ohio and West Virginia.

And despite many other efforts, the Republican-controlled House and Senate could not pass a bill to fulfill the party’s pledge to end Obamacare.

As the first year of the Trump presidency neared an end, Obamacare remained mostly intact. Mostly.

Mind the Gap

“It has proven remarkably persistent. They kept stabbing at it and failing and failing,” said Simon Haeder, an assistant professor in political science at West Virginia University’s John D. Rockefeller IV School of Policy & Politics, where he focuses on health policy. But Obamacare did change and will likely continue to change in 2018.

One of those changes was included in the Tax Reform Act passed in December. Included in the bill was a provision to eliminate the ACA’s individual mandate, which required every American to have health insurance or pay a penalty. The mandate was a key to stabilizing health insurance markets and funding Obamacare.

Haeder said other upcoming changes will not be high-profile bills tracked through Congress tracked by the hour on cable news. Instead, he said, they are likely to be out-of-the spotlight, wonky tweaks to health policy regulations.

But such tweaks could lead to widely varying use of Medicaid from state to state and determine who has access to care to what kind of care. Because eligibility is based on income, Haeder said, this could have the greatest effects among poor people dependent on Medicaid.

“We are going to have states, where we have states that have low insurance like 4 or 5 percent like Massachusetts and Oregon and places like Texas and Alabama where you have 20, 25 percent uninsured,” he said.

Essentially, he said, Medicaid could become one level of service in one state and something completely different in another. That could already be happening as states file waivers with the federal government to alter some rules for eligibility for Medicaid programs.

Kentucky, one of the unhealthiest states in the nation, applied for such a waiver. The commonwealth becomes the first state requiring some Medicaid recipients to devote 20 hours a week to work, volunteering or school in order to keep their insurance. Health care advocates say that will be difficult in poor, rural areas with few options for transportation. Haeder fears that people will lose coverage because they can’t meet that requirement, shrinking Medicaid rolls.

For Kentucky, Ohio and West Virginia, where there are extremely high levels of cancer, diabetes and other chronic illness, that could mean the already staggering health gaps will grow in states where Medicaid is not embraced.

“The question becomes, when is the discrepancy between two states in the same country too large?” Haeder asked.

Rural Hospitals Concerned

Maggie Elehwany is the vice president of Government Affairs and Health policy for the National Rural Health Association. She said the differences among states are already vast and will get worse as struggling rural hospitals close. Losing them, she said, creates “health deserts” populated disproportionately by the elderly, chronically ill and the poor because people with better options for employment will move away.

That, she said, has real implications as the closest healthcare moves farther away and increasing the travel time beyond what is considered the first critical hour to get treatment for many serious, emergency health conditions.

“There have been so many documented case where patients just haven’t lived because their transport times were too long,” she said.

https://www.youtube.com/watch?v=jkIGJ8_7gkQ&feature=youtu.be

Elehwany said rural hospitals can also make up 20 percent of the local economy. That means losing a hospital is a multi-faceted blow. The well-paid professionals who work at the hospitals lose their jobs and usually are forced to move out of town. That leads to other businesses, such as grocery stores or banks, closing in the wake of the exodus of medical professionals.She said that property values in an area can even go down, further weakening a crucial source of local tax revenue.

“It really is the nail in the coffin for the economy of a community,” she said.

She said, in the end, denying access to basic, preventative care doesn’t save money. Those patients will put off care until something catastrophic happens and the cost of their care will skyrocket.

Positive Numbers

Dr. Van Breeding works at Mountain Comprehensive Care, a federally qualified health center serving patients in five eastern Kentucky counties. He was also named Country Doctor of the Year in 2017 by Staff Care, a national physician staffing firm that annually recognizes outstanding doctors in small towns.

He echoed Elehwany’s concern while speaking at a recent panel discussion about health care in Whitesburg, Kentucky.

He well knows the how bad health is in the region.

The patients he serves have the “highest levels of blood pressure in the United States, highest levels of opioid abuse, the highest levels of babies born addicted,” he said. “You name it, we have it.”

A study from the Appalachian Regional Commission showed those challenges are spread throughout the region and include some of the highest levels of cancer in the country, with Kentucky at the top of that list, and also shrinking life expectancy.

Dr. Van Breeding, director of clinical affairs, examines a patient at Mountain Comprehensive Care Corporation.

But Dr. Breeding said he sees access to Medicaid is making a difference every day for his patients. And other potential patients seemed to notice. In 2017, the time frame for signing up under Obamacare was cut in half and funding for outreach efforts was reduced.

Still, people signed up. Kentucky enrollment rates increase by nearly 12 percent in 2017 compared to the previous year. Enrollment in West Virginia and Ohio dropped in the same period.

Haeder said the never-ending noise over a revolving series of repeal and replace bills may have actually made a broader audience aware that they, perhaps, could be eligible to get health insurance, especially Medicaid.

Breeding also said people who receive health care and those who provide it have seen a measurable difference in the quality of life. That, he said, has the potential to change the future of those long-suffering communities.

“We are getting kids in for the vaccinations that they didn’t have, we are getting them in for flu shots, pneumonia shots, we are saving their lives, we are treating the conditions earlier,” he said. “If people, if politicians, are trying to manipulate the numbers they are lying. We have the numbers we have shown them the numbers.”

He said in his view the disconnect between politicians and patients is clear.

“Politicians are turning their backs on patients in need,” he said. “Our agenda is our patients.”

ReSource reporter Benny Becker contributed to this report.

Tobacco’s Toll: New Push To Stop Smoking In Country’s Sickest States

Hundreds of kids scurrying to buses are oblivious to a sign above them declaring Bourbon County High School “100 percent Tobacco Free.” But upstairs in the library, sophomore and anti-smoking advocate Jacob Steward unfurls a six-foot scroll with earth-toned papers trapped between clear sheets of laminate. He begins reading the anti-smoking slogans he’ll post around the school.

Cyndi Steele, with Steward, has been an advocate since 1993, eight years before Jacob was born.

“E-cigs pose threat to health and turn kids into addicts and gives big tobacco your money,” he said. “E-cigs, neither water, vapor or harmless.”

Steward is well aware that while his high school campus is smoke free, his central Kentucky community is not. Many kids wander off to a nearby lot to smoke. And many of the Bourbon County businesses where teens work part-time still allow smoking, exposing kids and other workers to secondhand smoke.

In fact, about 60 percent of Kentucky communities do not have an ordinance requiring workplaces to ban smoking. Data from the Centers for Disease Control show Kentucky and West Virginia have the highest rates of teen smoking in the country.

With bright red hair, sharp blue eyes and braces, Jacob is the face of Students Making A Change in their Communities, or SMACK. He also reflects the region’s tobacco heritage. His family has long been in the tobacco growing business. Both his parents are long-time smokers, although his mom has switched to vaping.

He said kids are using nicotine to cope with anxiety and often progressing to other addicting drugs. Kids including his best friend from middle school, who got in busted for trading vaping supplies with high school kids after his mom went to prison. That boy and others, he said, seek out nicotine.

“They try to fill that void with a drug or something that takes their mind off it for a little while, off the things that are happening in their home life,” he said.

Tobacco Nation

Kentucky, West Virginia and Ohio make up a third of what the anti-smoking group the Truth Initiative recently dubbed the “Tobacco Nation.” It’s a “country within a country” with high rates of smoking and tobacco-related diseases such as lung cancer and heart failure. People who live there tend to die young than in the rest of America. But Jacob and others are still working to solve the region’s original addiction crisis.

Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, said there is rightly a lot of discussion lately about the opioid crisis and the toll of heroin addiction in communities. But he said the region has two big addiction problems. The other?

“The nicotine in tobacco.”

Opioid overdoses claimed about 1,400 lives in Kentucky last year. According to the foundation, tobacco use and secondhand smoke kills nearly 9,000 Kentuckians each year and results in health care costs of $1.92 billion.

While Kentucky is perhaps the starkest example of tobacco’s toll, similar statistics are common around the The Ohio Valley region.CDC data show Kentucky and West Virginia have some of the highest adult and teen smoking rates in the country, and Ohio’s smoking rates are well above the national average.

A coalition of business, health, and nonprofits aims to limit smoking in Kentucky, “the country’s cancer capital.”

Chandler leads Smoke-Free Tomorrow, a collection of organizations ranging from the Kentucky Chamber of Commerce to the council of churches. They launched their latest fight against smoking at a recent rally in Frankfort, where Chandler said there are some readily available tools to change those grim statistics.

“We have two very easy answers at hand,” he said. “Increase the cigarette tax by a dollar or more, and smoke-free laws all across this state.”

Price Point

Kentucky taxes cigarettes at 60 cents–among the ten lowest state taxes in the country. Chandler said the $1 hike is important. If the price doesn’t rise by at least that much, he said, the increased costs are offset by coupons and special deals by tobacco companies.

Ellen Hahn is the director of a tobacco-control advocacy group at the University of Kentucky called BREATHE, which stands for Bridging Research Efforts and Advocacy Toward Healthy Environments.

She said raising taxes has been proven to be an effective tool in both keeping people from starting to smoke and pushing people to quit. But only at the right price point.

“Make sure the price of tobacco is high enough to keep people who are price sensitive, like youth, pregnant women and low income populations, off of tobacco,” she said.

But while smoke free ordinances and tax increases have been successful across the country, here in the Ohio Valley region, she said, for every step forward like there is a step back.

Many Bourbon County businesses where teens work part-time still allow smoking.

In West Virginia, for example, while about three-fourth of West Virginians live in places with a smoke-free workplace law, this summer the state slashed staff in its smoking prevention program, eliminating all but one of eight positions.

Ohio, she said, has had a statewide workplace ban on smoking for a decade but still has high rates of smoking and the diseases associated with tobacco use.

But, she said, she that change is happening because the issue is so complicated. “It there was an easy answer we would have found it by now.”

Tobacco Tradition

And then there is the issue of the tradition and historic importance of tobacco in the region. Even in Lexington, one of the first places in the state to enact smoking restrictions, visitors to Hahn’s BREATHE office are likely to walk through a smoke-filled sidewalk to get to her door.

That deeply rooted connection with tobacco is something Cyndi Steele knows well. Steele is the advisor to Jacob Stewart and the SMACK team. She’s been an advocate at the Bourbon County Health Department for 24 years and knows the heritage of smoking.

“It goes back to heritage,” she said. “It’s what put Christmas in the house, it’s what paid the farm bill, it put kids through college, it built the courthouse. That’s what I heard for years, is ‘that tobacco built the courthouse’.”

“But it certainly does not do that anymore,” she said, “and when you know better you do better.”

Changing Times

Jacob’s grandparents, whom he calls Nan and Pa, had 65 acres of tobacco in 2014. Now it’s just 10. Instead of growing a product that can harm people, they are now growing mums. Jacob is proud that the mums grown by his family are used in school fundraising projects in Bourbon County. That, he said, means it is a positive for both the family and the community.

Plus, he said, the perception of growing tobacco is changing.

“It is really just people realizing how dirty of a business tobacco is and people getting involved and understanding the risks of tobacco.”

He’s worked the fields himself and can rattle off each painstaking step of the process from soaking the tobacco stakes in bleach to carefully putting the seeds in the correct place for the most growth.

He’s not a fan.

“It’s hot and it’s sweaty and a lot of times it’s nasty,” he said.

Jacob said this is the year that Bourbon County will get a smoking ordinance. He’s got a winning strategy for convincing elected officials. One he’s perfected on his still-smoking mom.

Nagging.

“When are you going to quit. When are you going to quit,” he said. “After a certain point of pestering, they get tired of hearing it.”