MOUNT MORRIS, Pa. -- Lois Bowlen had to pile her family into the car for a half-hour ride if their ailments were beyond what the home medicine chest could handle.

	Martha Rial, Post-Gazette Nurse practioner Mona Counts listens to Jack Vance, 79, talk about his family at Primary Care Center of Mount Morris in Greene County. Mr. Vance, who is from nearby Pursglove, W.Va., came to the clinic because he was concerned about his recent weight loss. Click photo for larger image. Related article Tiny Mount Morris clinic meeting a critical need

Just the prospect of driving the hilly roads from tiny Kirby, Greene County, to seek out health care in Waynesburg or Morgantown, W.Va., was enough to drive them back to bed instead.

"When it's not convenient, people tend to say, 'I'm not that sick,' even when there are things they really need to be treated for," said Mrs. Bowlen, 47, as she arrived for her yearly checkup last week at the Primary Care Center of Mount Morris, a village of about 900 on the Pennsylvania-West Virginia line, five miles from Kirby.

"But then the small cold gets worse. And then you need the emergency room," she said. "Oh, my heavens, if this small facility was not in this community, they wouldn't go."

For Mrs. Bowlen and others who live in rural southwestern Pennsylvania, this humble 12-year-old clinic staffed by nurse practitioners on a former used-car lot is the resource that helps them to get well and stay well. About one-third of its 5,000 patients are uninsured or under-insured, with deductibles so high they end up paying thousands of dollars out of their own pockets.

For far too many other people in this corner of the state, access to health care is limited or nearly non-existent due to lack of transportation, money or inclination to seek treatment.

That, health officials say, is a primary reason why Fayette and Greene counties rank so poorly -- worse than any other county in Western Pennsylvania -- in a recent study of life expectancy rates conducted by Harvard's School of Public Health.

The government-funded study, released earlier this month, examined health disparities and their impact on longevity in the United States. Among the factors considered: geography, gender, race, genetic background, income and cultural customs of residents in inner-city, suburban and remote rural regions.

The study showed that people live longest in Hawaii, where life expectancy is 80 years. Ranking last were Mississippi, 73.6 years, and Washington, D.C, 72 years. Pennsylvania ranked 31st, with a life expectancy of 76.7 years.

The study also showed wide disparities between ethnic groups and regions, indicating that Asian-Americans are likely to live at least a decade or more longer than African-Americans in the Deep South or urban areas with high homicide rates.

In Pennsylvania, the study showed, residents of urban Philadelphia County are likely to die youngest, at 72.3 years. McKean County came in second to last in the life span ranks, at 75.7 years. Tied for third place were Fayette and Greene counties, at 75.8 years.

Residents of Centre County had the longest life expectancy, at 79.4 years, followed by those in Cumberland, Montgomery, Northampton and Union counties, which tied at 78.8 years. In Allegheny County, the life expectancy rate was 76.7 years.

Health officials said life expectancy rates for Pennsylvania counties are in line with the national findings and reflect the effects of problems that are not unique to the region -- obesity, poor diet, sedentary lifestyles, smoking, pollution and other issues.

So why are residents of Fayette and Greene more likely to die up to two years before their neighbors in Washington, Westmoreland and Somerset counties, where people live to age 77 or longer?

"We are a tranquil, peaceful county and at first I was surprised by this," said Greene County Commission Chairwoman Pam Snyder, an advisory board member at Southwest Regional Medical Center in Waynesburg, the county seat.

"But then when I think of the industries and problems here, maybe I'm not so surprised. Coal miners don't have the life expectancy of someone who hasn't been breathing black dust all their lives. And it's not just about having a job, but having a job that provides a quality of life."

Heart disease and cancer are the top two causes of death in both counties, and the numbers of deaths from heart disease have been higher than rates for all counties for 10 years, according to state Health Department statistics.

Greene County also has a higher rate of deaths from cancer than the statewide rate, although Fayette's number of cancer deaths has been slightly lower than the all-counties rate in recent years.

The third leading causes of death are strokes in Fayette and accidents in Greene. Again, those rates are higher than the all-counties rates, and the rate of alcohol-related motor vehicle accidents in Greene County has been nearly four times the statewide average for 2000-04, the most recent years for which statistics were available.

Rates of diabetes-related deaths in both counties also have been sharply higher than the all-counties rates in recent years, although the death rate in Greene dropped slightly below that rate in 2004. In Fayette, however, the county rate of diabetes-related deaths in 2004 was nearly 60 percent higher than the all-counties rate.

Poverty is perhaps the most obvious factor lowering life expectancy in both counties, health officials said.

The two counties regularly rank among the state's poorest, with an estimated 15.9 percent of Fayette County residents and 14.6 percent of Greene County residents living in poverty, according to U.S. Census statistics. The statewide rate was 10.6 percent; the national rate was 12.5 percent.

Both counties have few industries other than mining, and unemployment rates of 6.7 percent in Greene and 7.8 percent in Fayette also are higher than the statewide average.

People who are working often lack health insurance, and others with subsidized insurance may find that some doctors won't accept it. They may choose to pay for food before medicine or treatment, but the food some people buy is likely to be cheap, served with fries and followed up with cigarettes.

Lack of education also affects the life-expectancy rate, health officials said. So does a tough-it-out mentality fostered among self-reliant Appalachian people who stay close to family, care for each other and turn to home remedies rather than "city" strangers.

"Sometimes they don't like doctors or trust doctors," said nurse practitioner Debbie Stroop, a trauma program coordinator at UPMC Presbyterian in Pittsburgh and a partner in the Mount Morris clinic. "They don't like when doctors dictate what they should or ought to do."

But perhaps the greatest factor for residents of this rural area, officials said, is lack of access to facilities where they can turn for convenient, affordable treatment as well as guidance on maintaining their health. All too often, they said, residents delay care until a minor problem escalates.

Poor residents of Pittsburgh or its suburbs who don't have cars can obtain free or reduced-cost health care at numerous hospitals, clinics or doctors' practices at the end of a bus route or short hop in a friend's car or jitney cab.

People with similar problems in Fayette or Greene County are more likely to struggle to get to a hospital or clinic 30 to 40 minutes away. Or they go to a hospital emergency room because they couldn't pay for care elsewhere.

"We'll see older folks, in their 50s and 60s, who will work until they are really sick. Then they apologize for coming in and bothering us when they're gravely ill," said Dr. Jeffrey Frye, emergency department director at Uniontown Hospital in Fayette County.

Fayette County has two hospitals, down from three since Tara Hospital at Brownsville closed early this year. Greene County has just one. Residents in remote southern villages in Greene County are closer but must cross state lines to reach West Virginia University Hospitals in Morgantown.

Public transportation in both counties is limited. Greene County has no bus lines and only a van/minibus program that must be scheduled.

Residents also rely on family practitioners and a handful of clinics. But recruiting and retaining doctors has been difficult due to Pennsylvania's malpractice insurance costs and low reimbursement rates for treating residents on medical-assistance insurance, Dr. Frye said.

Health care and county officials in Fayette and Greene said the longevity study results reinforce work they've been doing to address areas where care is needed. High on those lists are programs they're expanding to educate residents on preventing and managing diabetes.

Uniontown Hospital last month opened a diabetes center with the University of Pittsburgh Diabetes Center. Southwest Regional Medical Center is organizing diabetes support groups in Greene County communities.

Greene County officials are encouraging residents to exercise by expanding the Greene River bike trail through Rices Landing and Crucible, building a larger aquatics center near Waynesburg and constructing new tennis courts.

Ms. Snyder said she also expects health benefits from the installation of scrubbers to reduce soot and sulfur dioxide pollution from Allegheny Energy's Hatfield's Ferry power plant.

Next door in Fayette County, an 11-year-old Community Health Improvement Partnership of public and private officials has developed programs and sought funding to address obesity, smoking and nutrition, heart disease and other issues.

Dr. Frye also pointed to successful efforts at Uniontown Hospital to cut back on cases of congestive heart failure and teach residents about heart disease and the symptoms of heart attacks. But more outreach work is needed, he said, recalling a recent 26-year-old heart attack patient who passed up home-cooked, nutritious meals to eat burgers every day.

"Ultimately, you're talking education," said nurse practitioner and Penn State University professor Mona Counts, who founded the Primary Care Center of Mount Morris after neighbors heard she'd moved to the area and began showing up on her porch with sick children.

The center aims to be a one-stop wellness center where nurse practitioners in casual sweaters and jeans spend as much time interviewing patients about their lives and family histories as they do treating illnesses. Their homey approach has been so successful they will break ground in the next year for a larger building.

"People have free will and they will choose the actions they wish to implement. But do they know enough to choose the right action?" Ms. Counts said. "Our mandate is to partner with people, to help them understand and give them choices. The primary thing is to engage them in their own health."