Where healthcare won't go: Marion, Alabama

May 14, 2017 9:32 AM

The rate of TB infection in Marion, Alabama is a hundred times the national average, and even higher than Haiti, India, and Kenya. There is no hospital in town, two ambulances in the county, and life expectancy here is seven years lower than the US average. Marion sits in the belly of the Black Belt — historically, a ribbon of seventeen counties in central Alabama and parts of northeastern Mississippi, where whites enslaved black people to farm cotton in the dark, fertile soil; the term has come to refer broadly to predominantly African-American areas in the rural South.
posted by stillmoving (21 comments total)

Fucking sickening. No pun intended.
posted by nevercalm at 10:15 AM on May 14, 2017 [2 favorites]

Fascinating article. I wonder if nurse practitioners and physician assistants might be a viable option in such places.
posted by davidmsc at 10:30 AM on May 14, 2017 [1 favorite]

Having more NP and PA will help in the same way having more doctors will help. PA and NP end up being distributed in a similar fashion to physicians. Unless our healthcare providers are tied to the community to serve this won't really change.
posted by roguewraith at 10:46 AM on May 14, 2017 [3 favorites]

A really interesting read.

I found some of the author's emphasis a bit strange: she made a big deal of the fact there is no hospital, and the nearest one is twenty miles away, but that seems normal enough to me for a town of three and a half thousand people. I wish she had given some more background about what kind of medical services are considered normal for small towns of this size.
posted by Azara at 10:50 AM on May 14, 2017 [6 favorites]

Yup, I've driven through Marion, and cross pretty much the entire black belt, many times while going to visit my father's side of the family in northern Alabama from my mom's side of the family in south Alabama. This surprises me not one bit.
posted by RolandOfEld at 11:01 AM on May 14, 2017

Fascinating article. I wonder if nurse practitioners and physician assistants might be a viable option in such places.

Not without changes in Alabama law, unfortunately. Nurse practitioners have significantly less power to practice without working directly under an MD in Alabama than in most other states. This also has the effect of there being none of the CVS or Walgreen's walk-in clinics in the state, since they would be required to have a medical doctor instead of a NP. It also has a brain-drain effect of in-state NP graduates.
posted by ndfine at 12:35 PM on May 14, 2017 [8 favorites]

Not just in Alabama, a South Carolina outbreak in 2003 infected fifty school kids. The state's incompetency and lack of transparency was a major embarrassment for Nikki Haley.
posted by Public Corruption? at 1:11 PM on May 14, 2017 [2 favorites]

Medical schools (and society) are too focused on high achievers rather than on doctors who would serve communities in need.
posted by SyraCarol at 1:16 PM on May 14, 2017 [11 favorites]

This lack of access to care also plays a role in our excessive maternal mortality rate, among many other healthcare measures where we lag behind the developed nations. (I would normally say "rest of the developed nations" but lately I'm not so sure.)

The next time some tries to say health care isn't a "right" you can point them to Article 25 of the Universal Declaration of Human Rights:

(1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

I know that argument won't convince the John Bircher types, but the US (particularly Eleanor Roosevelt) helped write that document and is a signatory to both the declaration and supporting treaties. Once again exceptionalism rears its ugly head as we tell other countries "do as we say, not as we do."
posted by TedW at 1:32 PM on May 14, 2017 [10 favorites]

Good article!

This seems significant and relevant also to the discussion over in the endless politics thread:

Todd has a son, who is seven, and he had been going to the same public elementary school that she attended. She was worried that his prospects would be limited if they remained. As he gets older, she wants him to meet a more diverse group of people — a different group — and have access to greater opportunities, the ones that had yet to come to the Black Belt. “That’s the most unfortunate part about living here,” she told me. “We’re not progressing at the same rate as everything else around us.” She sighed. “We’re just kind of stuck.”

At the restaurant, we slid into a booth. “This is one of the few places in town I can come and not see eight people I know,” Todd said. People have come up to her at church and asked for medication refills, stopped her in the grocery store for their test results, knocked on her door at night with medical queries. Being the only doctor in town, she felt like she was at work all the time.

And in her personal life, she was isolated. Most of her peers lived in cities with greater employment potential. Few of her childhood friends with professional degrees had returned to Greensboro. Her mother had worked in a sewing factory and her dad was a truck driver; she was the first in her immediate family to graduate from college. “People think you are a millionaire,” she told me. “To make six figures in a town where people don’t earn that sort of living.”

Now she was discouraged by a forsaken quality of her hometown. “One person just can’t do it,” she said. “It sounds very nice, but one person cannot change everything.”

Creating a community with adequate healthcare is not just about opening a clinic or a hospital, it's about the whole social infrastructure, about schools, churches, other jobs for professionals, and that change takes more than funding and educating local doctors. If you are a young doctor, and your fiancee is a lawyer, you won't be going to a rural backwater. If you are a professional with children, you don't want to have to choose between a private school or a segregated poor public school. If you have a vulnerable old person you are caring for, you want access to excellent healthcare and now the whole thing is spiralling down.
posted by mumimor at 1:44 PM on May 14, 2017 [11 favorites]

Tell me again how the ACA was good enough.
posted by byanyothername at 3:03 PM on May 14, 2017 [3 favorites]

The ACA seems like a moot point, now that it is being cut back or eliminated.
posted by eye of newt at 3:16 PM on May 14, 2017 [4 favorites]

"Good enough" was never the issue. A foot in the door is the issue.

And the article makes it clear that, with the Medicaid expansion, things would have been very different.
posted by steady-state strawberry at 3:21 PM on May 14, 2017 [18 favorites]

Frankly, the discussion wasn't about whether the ACA was good enough. It was about whether it was better than the real alternatives.
posted by the agents of KAOS at 4:16 PM on May 14, 2017 [4 favorites]

Tell me again how the ACA was good enough

The ACA was a start, maybe not the best start but a BIG step in a good direction. If not for total opposition by the GOP to every attempt at improving it, it would have been getting much better.
posted by anadem at 5:51 PM on May 14, 2017 [3 favorites]

The most sympathetic figures here are the anti-ACA state government which pulled out all the stops and more to respond to the outbreak, and the villains seem to be stuck-up American doctors who just can't bear to live anywhere uncool. And the solution they seem to keep coming back to is further lowering the minimum MCAT score for kids from these communities to be admitted to medical school, which in an era of declining residency slots and increasing technological and quantitative facility required for practice for seems likely to result in a generation of nice kids with $250k in loans and no job to show for it. And the solution actually at work in the county -- doctors from the subcontinent who aren't too fancy to practice in the countryside -- gets a one sentence dismissal.
posted by MattD at 9:53 PM on May 14, 2017 [1 favorite]

the villains seem to be stuck-up American doctors who just can't bear to live anywhere uncool.

I know you're not saying this, at least I think you're not since it's early and I haven't had coffee yet, but living in a place like this, while not exactly one of those "be our nurse practitioner for this community of 300 on this island off of Scotland/remote Inuit community type of thing" it's quite similar. This is not living in a small town outside of Chicago or 1 hour from LA or what not. When the nearest town of larger than local import is Tuscaloosa and you maybe don't pull for college football teams and the next largest town is Montgomery (which has never really thrilled me as an Alabamian) and the next nearest is maybe Mobile at 3+ hours drive away which, sure it has some culture and beaches nearby but damn that's a haul for anyone...

I don't judge these doctors for not being able to carry the burden on their own, not one bit.
posted by RolandOfEld at 6:38 AM on May 15, 2017 [3 favorites]

Not to mention: How are they supposed to pay off their student loans serving a town of a thousand people where everybody is broke? The reason "doctors from the subcontinent" are taking those jobs while American-trained doctors aren't is that they can afford to, because their medical education in India didn't burden them with a crippling amount of debt. It has absolutely nothing to do with who's "fancy" or not.
posted by tobascodagama at 8:26 AM on May 15, 2017 [1 favorite]

and the villains seem to be stuck-up American doctors who just can't bear to live anywhere uncool.

That seems like a remarkably uncharitable read of the motivations of doctors, particularly given that one of the doctors they profiled was leaving because she couldn't find an acceptable way to educate her seven-year-old son in a deeply dysfunctional educational system.

But I do think that you're gesturing towards something true with your mention of declining residency slots. This situation is the worst example of a much bigger problem, which has to do with the fact that the American medical education system is not in any way up to the task of creating the medical workforce that we need. This problem is most pressing in rural communities and black communities and especially rural black communities, but at some point it's going to affect all of us. We need to figure out a way to train more primary care doctors and to convince them to work in the communities that most need their services. And that may mean shifting emphasis away from recruiting med students with the absolute highest grades and scores, because that's great for training high-powered specialists, but we don't have a shortage of high-powered specialists. We have a shortage of primary care docs, and that's only going to get worse. And I don't think we're going to be able to solve this problem by recruiting a bunch of doctors from Pakistan, if only because other things going on in our political culture are going to make it increasingly difficult to do that.
posted by ArbitraryAndCapricious at 8:49 AM on May 15, 2017 [6 favorites]

The next largest town to Marion would actually be Birmingham and the suburban areas around Hoover. Montgomery wins more mentions in the article because it's the state capital. State health workers are more likely to come to Marion from there.
posted by raysmj at 9:08 AM on May 15, 2017

Wow, everything about this article is super distressing. The lack of primary care providers, people's justifiable skepticism about the providers who do exist, the fact that TB is resurgent at all, the fact that Alabama didn't expand Medicaid for the usual shitty bootstraps reasons. What a perfect storm of horse shit.

I also want to comment on the "why not NPs and PAs" question, because I keep hearing about how NPs will save rural primary care and I am skeptical as a nurse myself.

So, the shortage of primary care physicians is a known thing, and part of the reason for that shortage is that primary care is considered lower prestige, and has correspondingly lower pay. (The reasons for that low prestige/low pay may be because talking people with low health literacy and significant chronic conditions is HARD and is coded feminine in a way similar to classroom teaching, but I digress.) Problem is, nursing has its own internal hierarchy of prestige that's not unlike the one physicians have. Nursing school focuses heavily on hospital nursing over community health nursing, and even nurses who want to work in the community like me are encouraged to work in a hospital first "to develop your skills." Within the hospital, ICU and OR nursing are considered "the hardest" and therefore most prestigious. Of the various types of nurse practitioners, nurse anesthetists make the most money, and most nurse anesthetist programs require critical care experience first. General hospital floor--ICU--CRNA program is a pretty common progression if you're into that sort of thing.

Meanwhile, my nursing program only had one semester of community health with one associated clinical rotation, even though "community" is a broad field that includes public health clinics, home care, school nursing...the list goes on and on. My school in fact just revamped its program to focus more on community health and social justice, and there are apparently people up in arms that it's too soft and abstract and doesn't prepare people for "the jobs we'll actually be doing." Hell, before they even implemented the curriculum my graduating class was up in arms on behalf of the new students. Hard enough to get people interested in going to underserved areas in Philadelphia, let alone little towns with deeply entrenched poverty and distrust like Marion.

Given this climate among nurses and nursing students, how do policy wonks expect NPs to swoop into rural areas and save the day?

As a wannabe public health nurse, I had to forge a lot of my own paths in school. One way I did that was by volunteering at a nurse-run foot care clinic that operates out of a homeless shelter. The NP who founded that clinic is white and not a Philly native, but she's earned people's trust by working with homeless populations for years. She once told me that the way she knows her clinic is working is hearing from patients that we have a good reputation on the street. Not by metrics of how many people we served, or how many volunteers stick around, but by how our people spread the word that we're trustworthy, offer good medical care, and don't treat them like pariahs. Building this sort of goodwill is the goal that all practitioners working with underserved populations should strive for. But that goodwill can only happen with providers who are willing to stick around a given area, who don't treat serving poor people as a line on a resume. Federal and state governments aren't willing to provide the infrastructure to make that happen. Medical schools aren't preparing doctors to provide that kind of care, to form those deep relationships. Nursing schools aren't doing much better, despite the constant exhortations for us to save healthcare.

If governments, doctors, and nurses have no incentives to serve the people who need the most care, who the hell does?
posted by ActionPopulated at 11:01 AM on May 15, 2017 [10 favorites]