Homegrown Healthcare, Homegrown Communities: An Interview with Wendy Welch

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Living out the Eighth Great Commitment, which charges us “To serve the Appalachian region primarily through education but also by other appropriate services,” is one of many factors that led the College to build the Margaret A. Cargill Natural Sciences and Health Building. Once completed, the facility will improve science education and, over time, increase the number of graduates who return to the region as healthcare professionals, something the region needs for many reasons. Appalachian communities continue to struggle with cancer, diabetes, heart disease, and stroke at rates well above the national average, according to the Appalachian Regional Commission (ARC).

Why these differencesbook-photos-004 persist, and how to address them, has been the focus of intensive study over the last 50 years. To better understand the current situation in the region, I visited with Dr. Wendy Welch, an ethnographer who runs the Graduate Medical Education Consortium (GMEC) at the University of Virginia-Wise. She is also the editor of a collection of scholarly essays, Public Health in Appalachia: Essays from the Clinic and the Field, but is probably best known as the author of The Little Bookstore of Big Stone Gap: A Memoir of Friendship, Community, and the Uncommon Pleasure of a Good Book.

How is GMEC helping improve healthcare in the region?

A lot of what we do in GMEC is, as we say, the three Rs, recruit, retain, and roots. By roots we mean “home grow.” We’re looking to develop medical professionals who can help build the infrastructure and the long-term sustainability of a system by having our own people work here. We need doctors who grew up here, who understand automatically what it means to be an Appalachian in the coal fields, who go to medical school, come back, do their residency here, and then set up a practice.

What makes bringing young healthcare professionals back to the area a challenge?

First, we have the problem that the best and the brightest are too often skimmed off in urban areas. When you have really, really smart kids who are from here and who get it (the culture), they know their ability to make more money, their ability to pay off their student loans, which are hefty for doctors and dentists, is faster and simpler in an urban area than here.

The less support they get from grant assistance programs or a debt forgiveness program, the more likely they are to feel pressure to work in an urban area. What I do a fair bit of is simply making sure that people can make informed choices not only about debt forgiveness but also about how much it’s going to cost them to live here versus living in an urban area. The cost of living here is lower, and that really needs to be factored into the overall equation. Unfortunately, that hasn’t been a conversation that we have had often enough in the past with would-be professionals.

Second, there are those stereotypes, those unfounded stereotypes of what it means to live in Appalachia. Fairly often, we hit those pretty hard, too.

Why is retaining these young people important to the communities in the region?

One of the reasons we like to see our doctors come back with a spouse is because that spouse is going to be a professional, too. The community gains a new head teacher or the director of a daycare. When you bring a doctor back to his or her home community, you’re often bringing a whole family of professionals, and you are planting the seed of future development.

We love telemedicine, but that approach cuts out the economic development that happens with a doctor on the ground. One doctor in a rural community is worth 1.2 million per year in economic activity.

Not to mention that most rural communities like ours have that doughnut hole in their populations. Our 18 to 24-year-olds go to the local college, but then they go away to graduate school. They disappear because the job prospects are in urban areas. They raise their children in the urban area, launch their families, then look around for a retirement job because they can retire at 45 or 50 and come back to a rural community. In the last census, our 65+ population grew by 5 percent. Our 24-40 population dropped by 15 percent.

How does being from Appalachia help that student solve some particularly interesting or challenging problem that the region faces? How does it better prepare them to be part of that solution?

One of the reasons I edited the book Public Health in Appalachia, and one reason we look for homegrown students, is the belief that if the problem’s in the community, then the solution is there as well. It’s in the kids who have grown up watching their grandmother battle with type 2 diabetes while cooking chicken and dumplings for Sunday dinner every week. Kids who have also seen her growing a beautiful vegetable garden. It leaves them wondering, why does grandma have type 2 diabetes if she has all the healthy food in the garden? Well, she’s getting government commodities, she’s getting government flour, she’s getting government pork fat, and this child — before she knows what she’s seeing — already has half of the solution in her head because she’s seen the difference between, “this is what you need to eat” and “this is what we’re going to give you for free.”

By the time she hits high school and learns about nutrition, she’s starting to understand what’s not working: They’re handing out lard to the poor people. It’s amazing how much common sense is missing from the way that we approach healthcare problems. I think in large measure that’s because the people who are from the region don’t stay so they can’t stop the bad solutions from starting.

If we bring these students back, they can apply their combination of cultural competency from growing up here and what they learned in residency about nutrition; they will have a real chance to succeed.

Those are the people we’re looking for, the people with the heart and the mind, and the background.

What can be done to bring the Appalachian students back to the region?

I think over the long haul, we’re seeing a new generation of Appalachian kids who want to go back to the land. We have a whole generation of college-educated people who have day jobs but won’t shop at Walmart because they’d rather grow their own food. People who are learning to live sustainably, not because they think it’s fun, but because they think it’s going to be necessary.

I think these kids are seeing the big picture of what’s going on, and they’re working to make sure their kids can live the way they live. They’re working for a sustainable Appalachia, and I think that’s one of the best things that can happen.

The more we have this new generation of Appalachia rising — a lot of books that characterize them this way — the better off the region will be. I’m talking about people who have thought about how they can live an economically sustainable, viable community lifestyle, and hold down a job doing work they enjoy. I think that changes not just Appalachia, but the world.

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