Southwest Virginia: One of the Nation’s Unhealthiest Regions?

Rural Appalachia: Disparities Within Disparities 

by Michelle L. Salob, ND, MPH  

For those living outside the region, rural Appalachia has historically conjured up images of poverty and despair. Eleanor Roosevelt visited the area during the New Deal era, highlighting the plight of the coal miners, but since then, there has not been much attention to an area that is stricken by poverty and unemployment. Movies like “Deliverance” have portrayed the Appalachian region as one of backward living and incestuous relationships. For decades, rural Appalachia has been relatively hidden from view, and as a consequence, the health disparities within the area have gone largely unnoticed by the general public. The resilience and determination of the people of this region has kept a small but dedicated group of volunteers, health care providers, and academics working in the area.

Figure 1: The Counties of Appalachia by Subregion (Appalachian Regional Commission)
Figure 1: The Counties of Appalachia by Subregion (Appalachian Regional Commission)

While isolated local efforts by volunteer, academic, and faith-based groups in communities in rural Appalachia have been providing various interventions and services, the need for more collaborative efforts exists to strengthen local social capital. A recent media piece by Diane Sawyer on ABC’s 20/20 has sparked somewhat of a national resurgence in interest for the area, which will hopefully lead to the further development of interdisciplinary and community-based research and interventions to address the health disparities of Appalachia. Examined will be variables contributing to the health disparities in rural Appalachia, with analyses of specific research and interventional efforts in the area. A general overview will be provided, followed by examples of strengths and limitations in the current research in efforts to identify future direction of targeted strategies for identification and elimination of these disparities. 

Appalachia is the geopolitical term given to the area surrounding the Appalachian mountain chain in the eastern United States, extending from southeastern New York to northeastern Mississippi, an area covering about twelve hundred miles, and broken down into 3 subregions of northern, central, and southern Appalachia based on topographic, economic, and demographic homogeneity. This area encompassed 399 counties in 1998, of which 299 were classified as non-metropolitan (rural).

For fiscal year 2009, 81 counties in Appalachia qualified for distressed county status, due to low per capita income and high rates of unemployment and poverty. According to figure 2, the majority of these counties are clustered in and around Kentucky, Virginia, and West Virginia (central Appalachia). Further analysis reveals that 38.6% of counties are considered to be distressed or at-risk of becoming distressed. Almost 94% of the counties in Appalachia fall below the top quartile of counties in the US. Only 7 counties out of 420 (1.67%) in Appalachia have reached the status of attainment, which includes the top ten percent of counties in the US. 

Figure 2, County Economic Status, Fiscal Year 2016
Figure 2, County Economic Status, Fiscal Year 2016

Note: The Appalachian Regional Commission derives these county designations based on an index-based county economic classification system based on a comparison of county averages for three indicators (three year average unemployment rate, per capita market income, and poverty rate) with national averages. Each county is indexed and ranked into one of the following five categories: distressed, at-risk, transitional, competitive, and attainment. Distressed counties rank in the bottom 10% of counties in the US, representing the most economically depressed regions in the country. At-risk counties are slightly better off than distressed, and fall within the bottom 10-25% of US counties. Transitional counties represent the median economic condition, ranking between the second and third quartiles. These counties can represent economies that are either weak becoming strong, or strong becoming weak. Competitive counties rank between the top 10-25% of US counties and are considered able to compete in the national economy. Attainment counties represent the counties in the US with the top 10% economic conditions. 

For the purposes of this paper, the majority of the discussion will focus on the economically disadvantaged areas of Appalachia, mainly the rural counties and concentrated most heavily in the central region. It is of note to mention that there are disparities developing within the Appalachian region itself, with areas such as the Atlanta metropolitan area gaining in economic growth, while areas in central Appalachia are increasing in poverty. These disparities, notably in educational attainment and poverty, can hide the true extent of disparate indicator variable in the region when compared as a whole to the US. 

The author, Dr. Michelle Salob, earned a BS in Rural Sociology from Cornell University and a Doctorate in naturopathic medicine from NCNM (National College of National Medicine, one of four accredited schools in the United States that teach naturopathic medicine). Following her medical training, she completed two years of residency, primarily at Outside In and other outreach clinics. Her primary interest is in health disparities, and she currently practices in NCNM’s community clinics working with medically underserved patients including those with addiction problems. After several years of supervising students at Outside In, Dr. Salob became interested in the structural aspects of health and community medicine. This interest led her to Yale to earn an MPH (Masters in Public Health) in its nationally acclaimed Advanced Professionals program. Dr. Salob’s research interests are in community-based participatory research, as well as qualitative methods as applied to vulnerable populations (especially homeless youth and adults). She is especially interested in the intersection of health and human rights, with the ultimate goals of helping communities address their self-identified needs and promoting sustainable health measures through collaboration and education. She visited Southwest Virginia to expand her knowledge of health care issues here and has agreed to share her findings with Mountain Peeks readers. 

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