Downtown Waynesville could feel the not-so-pleasant trickle-down effects if a proposed smoking ban on Haywood County property goes through.
The county ban would evict smokers from the grounds of the justice center and historic courthouse. Striking out in search of safe harbor, they would no doubt make their way to town sidewalks to light up.
But this year, an unprecedented study compiled health rankings for every county in each state across the country.
The results weren’t good news for Swain County, which ranked in the bottom 10 percent in several categories. However, Haywood, Jackson and Macon counties went against the stereotype of poor health in the Appalachian Mountains and ranked in the top third.
“The western part of the state is a good deal older. When you control for that, the east part of the state seems a good deal unhealthier,” said Dr. Tom Ricketts, past director of the North Carolina Rural Health Research Program at the University of North Carolina at Chapel Hill.
Compiled by the University of Wisconsin, the study divided heath rankings into two broad categories: health outcomes and the health factors that cause them.
Swain County ranked 91st out of 100 counties in the state — the lowest ranking of any county in WNC when it comes to health factors. Meanwhile, Jackson, Haywood and Macon Counties are ranked in the healthiest third at 31, 19 and 15 respectively.
Diet, smoking, drinking, exercise, access to quality health care, social and economic factors, and the physical environment all play into the ranking.
“Health and health behaviors and care are all tangled up in a multi-complex system,” said William Aldis, a World Health Organization representative to Thailand who lives in Sylva and has taught health classes at Western Carolina University and at a university in Thailand. “You can never completely separate these things.”
Aldis said he notices the difference in health as soon as he steps off the plane and into the airport terminal when he returns to the United States.
“It surprises me when I come back how sick people look here compared to other countries,” he said.
While the University of Wisconsin study took on an enormous task, the rankings are not universally accepted by public health officials.
Linda White, director of the Swain County Health Department, has not used the information in any strategic planning because she thinks the data may be skewed.
She often compares Swain to Graham County in her planning because the populations are similar. But she noticed the study reported Swain to have the highest percent of smokers in the state while failing to report a percentage of smokers in Graham.
“It causes me to question the validity of the data,” White said.
Macon County Health Director Jim Bruckner said some counties may need to look harder at some of the statistics to determine their quality because of the sampling methods. But Bruckner said the health department has a lot it can glean from the statistics.
Every three years, the health department uses a variety of statistics to create a “snapshot” of health outcomes and contributing factors in Macon County. Bruckner said the county health rankings will now be included in the project.
“We hope to use this report to shed light on what more we can do to help residents lead healthier lives and to mobilize community leaders to invest in programs and policy changes that will improve Macon County’s health,” Bruckner said.
The University of Wisconsin study looked at key health behaviors — which will ultimately affect people’s health in the future — such as diet and exercise, tobacco use, unsafe sex and alcohol use.
The study uses obesity as the measure for a county’s commitment to diet and exercise. Although obesity is a problem across the state, Jackson, Macon, Haywood and Swain Counties are no worse than the state average, according to the County Health Rankings.
North Carolina is the 10th most obese state in the nation with an adult obesity rate of 29 percent, according to the Trust for America’s Health “F as in Fat” 2010 report.
And North Carolina has grown heavier. In 2009, North Carolina was the 12th most obese state, 16th in 2008 and 17th in 2007.
“Obesity is one of the most challenging issues and has had the more lasting impact on our society,” said Carmine Rocco, Haywood County Health Department director.
Reducing childhood obesity is a big focus for health departments in Western North Carolina.
“We’ve attempted to combat that for years,” White said. “It’s a lifestyle change. Kids will eat what’s offered to them.”
White has worked with schools in Swain County to get healthier food on the menu. Between five and six years ago, the health departments removed the deep fryers from the school cafeterias and purchased them ovens instead, White said.
But it’s other health behaviors that earned Swain County its low ranking. Swain has the highest percentage of smokers in the state and one of the highest teen birth rates, which is used to indicate unsafe sex tendencies.
Dr. Mark Engel, a family doctor in Swain County, said he thinks part of the problem with Swain’s health is that preventative care has not been emphasized until recently and that Swain has been more isolated than the counties to the east.
“Swain has been socially isolated long enough,” Engel said. “It will be an uphill climb for better health.”
He’s noticed higher social support for both smoking and teen pregnancy, he said, adding that it will take generations to change the population’s attitudes.
Forty percent of adults in Swain County smoke compared to 23 percent across the state.
“We’ve come leaps and bounds,” White said, who questioned the accuracy of the statistics. “We work on lessening those numbers regardless of what they are.”
Both Dr. John Stringfield and Dr. Michael Brown, who are family doctors in Waynesville, said that they’ve seen a decrease in the number of smokers in their offices even though the study reports that Haywood still has a higher percent of smokers compared to the state average.
“There’s been an increase in education and peer pressure against smoking,” Brown said.
Only Macon County with 19 percent of the population being smokers falls below the state average.
Ricketts said that there is a strong correlation between smokers and more rural environments. He suggested that smoking might be a form of entertainment where few other options exist.
“It’s hard to explain,” Ricketts said. “It just is.”
Another key component in assessing an area’s health is the availability of healthcare. Researchers at the University of Wisconsin examined several factors, including the percent of uninsured adults, the number of primary providers in the area and preventable hospital stays.
Jackson and Swain Counties have poor clinical care rankings at 86 and 93 respectively while Haywood and Macon Counties are both in the top 15, according to the study.
“In the early ‘70s, the main problem was that there’s been a misdistribution between urban and rural areas with primary care physicians,” said John Price, director of the N.C. Office of Rural Health and Community Care. “The issue over the years has changed a little. The issue is economic access to care.”
Three of the four counties — with Haywood being the exception — have more than 22 percent of adults without health insurance.
That portion is noticeably higher compared to about 15 percent of American and 17 percent North Carolinians who are uninsured.
The Good Samaritan Clinic in Jackson County is a free clinic that treats uninsured adults. A volunteer doctor at the clinic, Dr. David Trigg, said there are often misconceptions about who the uninsured are.
“They’re not unemployed. They’re just uninsured, and they certainly aren’t lazy,” he said,
But in the clinical care rankings, other factors have a role in bringing down Jackson and Swain counties’ rankings.
Swain County has a high rate of hospitalization for typical outpatient services, according to the study. This suggests that outpatient care in the area is less than ideal or that the people overuse the hospital as the primary source of care, the researchers wrote.
A strike against Jackson County’s ranking is a low percentage of diabetic Medicare patients getting annual blood sugar control tests. The tests are considered a standard of good healthcare — a standard at which Jackson is the lowest in the state.
“One reason that could be lower is the way it’s recorded,” said Paula Carden, the Jackson County Health Department director. “Whether all the numbers get reported or not is hard to say.”
Carden said doctors are responsible for reporting the screenings when their patients come to get them. The codes used by doctors in Jackson to report the data may be different from those in other counties.
In one aspect of clinical care, the number of primary care doctors per capita, the study found all four counties at or above average.
But some of the physicians are counted twice, inflating the number of doctors for Western North Carolina. Many doctors in Jackson, Macon and Swain counties practice across countylines — with their main office in one county but a satellite office in the other where they hold weekly office hours. These doctors appear to be counted in both counties.
“Even if there are enough providers to the population by the numbers and they appear at the right levels, they’re not,” Good Samaritan Clinic director Becky Olson said. “The problem is that Jackson County doctors don’t just serve Jackson County alone.”
The study also fails to take into account the influx of seasonal residents and tourists to the area. Doctors in Western North Carolina said they can tell when the part-time residents begin to arrive in the spring.
“It’s an elusive number, hard to quantify,” said the Haywood County Health Department director Carmine Rocco. “But it’s a reality we have to deal with when we plan health care. If something happens, we have to be able to respond.”
Flu and respiratory illnesses keep his schedule filled during the winter, and during the summer, he sees an influx of seasonal residents. Some older residents who come for four or five months in the spring and summer have chronic conditions that require a physician’s monitoring, said Dr. John Stringfield, a doctor at Waynesville Family Practice.
“What keeps me busy is different for each season of the year,” he said.
But Ricketts said he wouldn’t call seasonal homeowners or tourists a stress on the Western North Carolina healthcare system.
“For a rural place, it generally does pretty well on physician supply,” Ricketts said.
He gave the motorcycle rally in Sturgis, S.D., as an example of something that would cause stress on the system. In 2008, the rally brought more than 400,000 bikers and three rally related deaths to the small town.
“[Tourism in Western North Carolina] doesn’t necessarily provide stress but provides income,” Ricketts said.
Research has shown that social and economic factors also play a key role in determining health.
“To have an overall picture of health, it’s affected by economic factors,” health director Carden said. “If you don’t have enough money for the good health care, your overall health is affected. … Economics plays an important role in our overall health whether we like it or not.”
According to the University of Wisconsin study, Swain County has the lowest high school graduation rate, fewest college degrees, highest unemployment and most single-parent households compared to the other three counties.
“More educated people are in a much better position to analyze health choices,” Aldis said. “Education is a powerful tool in expanding people’s health choices.”
Aldis said that in his work in foreign countries where the populations are less literate than in the United States, women who can read are more likely to get their children vaccinated even if they haven’t had any medical training.
But even less educated patients are attentive and willing to learn how to make better health choices, Trigg said about his patients at the free clinic. But without the clinic, they don’t have the same knowhow about getting health information, he said.
“They don’t get on the Internet and look up health information the same way someone from the university would,” he said.
Hand-in-hand with education, poverty also limits a people’s health options in that they can’t afford the best or at times adequate care, said Stringfield, a Haywood doctor.
“Those in a lower social economic status may tend to have more medical problems,” Stringfield said. “Sometimes that has to do with access to care or access to medicine. Many simply can’t afford to fill a prescription.”
Poverty also influences people’s food choices. Fruits and vegetables are expensive compared to a value menu at the local fast food restaurant. Snack food is also cheaper but contains unhealthy ingredients such as excess salt and high fructose corn syrup, Aldis said.
“There’s not a sense of autonomy of choice,” he said. “We have a very interesting inversion going on. Obesity is a disease of the poor.”
To learn more, visit www.countyhealthrankings.org/north-carolina.
The University of Wisconsin ranked all counties in all states by health outcomes and health factors. Within health factors, four subcategories determined the rankings: health behaviors (30 percent), clinical care (20 percent), social and economic factors (40 percent), and physical environment (10 percent).
There are 100 counties in North Carolina. A ranking of 1 would denote the healthiest county while 100 would signify the unhealthiest in that category.
Health Factor Rankings denotes overall health. The others show what went into determining the rankings.
Health Factors Rankings
Health Behaviors Rankings
Clinical Care Rankings
Social and Economic Factors Rankings
Physical Environment Rankings
Percentage of Smokers
State Average 23%