As a cardiac nurse at Uniontown Hospital, Diana Swanson is regularly dismayed by the number of heart patients who carry a pack of cigarettes and an extra 40 pounds when they show up for needed tests. When she worked at Forbes Regional Hospital in Monroeville, one in 10 stress test patients were overweight smokers, Swanson estimated.
But in Uniontown, the heart of economically distressed Fayette County, it's more like five in 10.
"When I came here to work in 1994, it was shocking to me," said Swanson, who has also lived in Westmoreland and Somerset counties. "There's a lot more people in Fayette County that I see smoking than in other counties. ... Overall, the county is poorer and I think people just seem to eat a lot of fast foods, higher amounts of carbohydrates and they are less educated about health."
More than 95 percent of Fayette County residents are white, yet the health problems they face are of concern to public health officials trying to raise awareness about racial and ethnic health disparities. That's because the health gap for whites in rural areas such as Fayette County and those in poorer urban neighborhoods is not unlike the gap experienced more generally by minorities.
Black men in the United States ages 45 to 54 die from coronary heart disease at a rate of 213.7 per 100,000, which is significantly higher than the rate for white men. Yet in Fayette County, white men in that age group die at a rate comparable to black men across that county and at a rate higher than that for black men in Allegheny County of the disease.
"When you look at populations in very urban inner-city neighborhoods and very rural neighborhoods, there are often commonalties in health issues and the underlying cause very often is income," said Michael Meit, who runs University of Pittsburgh's Center for Rural Health Practice in Bradford. "I don't want to discount the racial and ethnic issue, because racism is a tremendous factor in looking at health disparities. ... But I think very rural areas and inner cities have more in common in terms of health status than either has with suburban communities."
The Healthy People 2010 report, a massive federal guide for eliminating disparities in health care that are linked with race or ethnicity, also documents such disparities experienced by whites.
The report found that in 1998, for example, whites 45 and older were more likely than blacks that age to die from chronic obstructive pulmonary disease. The percentage of whites 50 and older who had osteoporosis between 1988 and 1994 was 10 percent, compared with 7 percent for blacks. Melanoma cancer death rates in 1998 were 3.1 per 100,000 in whites and 0.5 per 100,000 in blacks.
To address disparities faced by white and non-white groups, the federal government in January 2001 created the National Center for Minority Health and Health Disparities at the National Institutes of Health. Congress noted that whites comprise the largest single group of medically underserved people.
Stephen Thomas, director of Pitt's Center for Minority Health, said the name of the NIH center includes the words "health disparities" so that gaps faced by whites are acknowledged and studied..
"All the things we're talking about in the minority groups, you'll find a similar problem among some whites," he said. "It's not about race as biological construct. It's about the consequences of the social conditions that lead to ill health through poor health behaviors, lack of education, inadequate access to care.
"Wherever those social conditions exist, you have health disparities."
Social conditions play a big part in how disparities are regarded in Europe, said Dr. Kenneth Thompson, a professor of psychiatrist at the University of Pittsburgh School of Medicine. This spring, Thompson and Pitt hosted a national summit on developing community health partnerships to eliminate disparities.
Research in Britain has found that the health of different groups can best be explained by socio-economic class differences, Thompson said. Health disparities aren't simply a function of poverty, because health status improves as you go from working to middle and then upper classes, all of whom have plenty to eat.
Instead, disparities are a function of a broader concept that Thompson calls the "social ecology" in which people live. That includes the sort of foods they eat, their attitudes about risky behaviors such as smoking and a host of other factors.
"You're more likely to be injured accidentally or intentionally if you are in a lower socio-economic class," Thompson said. "You're more likely to have to sustain a period of homelessness the further down in the social classes you go and there's evidence that you're more likely to be exposed to toxic chemicals. Life events are different."
In rural areas, one facet of the ecology is the distance to care, which can be a barrier for some, said Meit, of Pitt's rural health center.
Sister Ruth Bearer, associate director of the Sto-Rox Family Health Center, said patient attitudes and education can be barriers to good health. Nearly half the patients treated at the center are on Medical Assistance and another 12 percent are uninsured, she said.
Whites and blacks treated at the center have similar struggles with health.
"I don't think it has as much to do with race as it does with attitudes toward health," she said. "The emphasis certainly now in health care is on prevention, but that's not the priority for many of our patients."
That's not unlike the situation in Fayette County. With the lower education level, there is less understanding of disease and prevention, said Swanson, the Uniontown hospital nurse. People know smoking is bad for them, but they don't understand that it dramatically increases their chances for heart disease.
Fayette County residents have access to three hospitals in the area and can be referred for care to major health centers in Pittsburgh. So, getting help isn't the problem, said Dr. Lewis Kuller, head of the University of Pittsburgh Graduate School of Public Health's Center for Healthy Aging.
"We have to deal with the reality that you have poorly educated people and people who don't have jobs or high socio-economic status," said Kuller, who is seeking a grant to expand heart disease prevention programs in the county.
The point about the economy makes sense to Jim West, 46, who completed cardiac rehabilitation at Uniontown Hospital last week. A resident of Greene County who lives literally a stone's throw from Fayette, West said the stress of living in a poor region is the best explanation for the higher rates of heart disease men his age face there.
West underwent surgery to clear a blocked artery this fall. He blames his own health problems on being overweight (he's 5 feet 9 inches and presently weighs 225), having a history of smoking -- although he quit seven years ago -- and not eating right. He sees those same problems in his peers.
But health concerns are crowded out, West said, "when you're worrying day in and day out about your electric bill, or about how you can't afford gas this week or how you've got a $500 insurance payment and you're making $6 per hour. ... It's easier to say, 'Let's stop at McDonalds,' feed the family for $15 and not have to do anything -- except clog up your arteries."
As a result, Dr. Veerunna Yadagani, a cardiologist in Uniontown, faces situations like this: Caring for a 500-pound patient who can't be evaluated with standard cardiac catheterizations or stress tests that measure heart function.
The reason?
"The cath lab table has a 400-pound limit and they weigh too much for the treadmill," Yadagani said. "I don't know where to go from there."
Christopher Snowbeck can be reached at csnowbeck@post-gazette.com or 412-263-2625.
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