Rural Health
Alumni are working to improve health care in some of the country’s most vulnerable communities.
In the shadow of shiprock, a dramatic volcanic butte rising over the plain in the northwest corner of New Mexico, stands the Northern Navajo Medical Center. It serves nearly 81,000 patients, mostly Navajo, and is located some 200 miles from the nearest hospital. Here, family physician Heather Kovich ’99 works alongside three other Williams alumni doctors, finding creative ways to care for a population facing increasingly challenging health and socio-economic concerns.
Twenty-seven hundred miles away, in Juneau, Alaska, pediatrician Marna Schwartz ’87 boards a small plane every Monday morning to spend the week treating patients in one of seven remote communities ranging in population from 400 to 2,500. One area is accessible only by oat plane; others lack roads. As one of 30 doctors working for the Southeast Alaska Regional Health Consortium, she is the main point of contact between the nonprofit and hundreds of children living in an extreme environment.
In central Massachusetts, Stephen Martin ’91 works as a primary care physician at the Barre Family Health Center, serving 40,000 residents in 10 rural towns spread across 350 square miles. ere he’s playing a central role in stemming teen pregnancy and the opioid epidemic, which has taken a disproportionate toll on small, economically disadvantaged communities. One of 13 providers at the center who are on the faculty of the University of Massachusetts Medical School, he’s also training a new generation of rural doctors and nurses as co-director of the Rural Health Scholars Program.
While shifts in the nation’s healthcare system are making it increasingly di cult to deliver medical care in rural areas—an already challenging proposition—these alumni and others are deeply engaged in serving their communities. For many, their preparation for this work began at Williams, where they discovered a love of the outdoors, immersed themselves in academics, or simply found kinship in a small, nurturing environment.
Says Martin, “I think it was the scale of Williams that imbued in me a feeling that an individual could make a di erence—and should make a difference.”
BALANCING COSTS AND CARE
Navajo Nation is by far the largest reservation in the U.S.—a 27,000-mile expanse of high desert and red sandstone blu s at the intersection of Arizona, New Mexico, and Utah. According to the U.S. Census Bureau, 41 percent of the population lives below the poverty level, and 22 percent is unemployed. Economic hardship, coupled with the fact that there are few inexpensive options for healthy eating, add up to a major problem: obesity, and its related health risks.
In addition to suffering from rampant hypertension and cardiovascular disease, an estimated 1 in 3 Navajo are diabetic or pre-diabetic, according to the Indian Health Service (IHS), a system of tribal health facilities staffed by 900 doctors serving 2 million Native Americans around the country. And there are twice as many new diagnoses of Type-2 diabetes among Navajo adolescents as there are among whites, according to the American Diabetes Association.
“Metabolic disorders and high blood pressure are the bulk of what I see every day,” says Kovich, a religion major from Philadelphia who “learned to be an outdoorsy person at Williams” and volunteered with the Appalachian Mountain Club during summer breaks.
She earned her medical degree from Temple University in 2005 and came to Shiprock in 2009. When she arrived, she found what the U.S. Department of Agriculture calls a “food desert.” There are fewer than a dozen grocery stores in Navajo Nation, an area nearly the size of South Carolina. Many residents eat at fast-food chains and shop for food at local convenience stores, where a frozen pizza is cheap but a bag of apples (if available) might cost $6.50.
To help curb obesity, the medical center hired a nutrition technician to provide classes in English and Navajo and make home visits to help families cook healthy meals with the items available to them.
“If the family has a propane tank and commodity foods with 30 jars of peanut butter,” Kovich says, “they’ll brainstorm how to cook something healthy.” They might learn a recipe for creamed peanut soup that calls for celery, onion, butter, our, evaporated milk, and peanut butter, or for “commodity bran chewies” using peanut butter, brown sugar, light corn syrup, bran flakes cereal, and raisins.
One of Kovich’s colleagues, OB-GYN Jean Howe ’84, sees the impact of poor nutrition, especially sugar consumption, in pregnant women. When too much sugar passes across the placenta, it can cause the unborn baby to grow large, adding to the mother’s risk of cardiac abnormalities, miscarriage, and complications during birth.
To lower these risks, all pregnant women receive a glucose monitor and education about healthy eating, exercise, and medication during their prenatal visits. As a result of these interventions, the percentage of babies born overweight at Shiprock has dropped from 45 to 7 between the years 2005 and 2014, Howe says.
A North Adams native, Howe majored in biology and taught high school math and chemistry in the Congo as a Peace Corps volunteer before attending the University of Vermont College of Medicine. She worked in the economically depressed town of Chinle, Ariz., in the heart of Navajo Nation, for 12 years before arriving in Shiprock in 2009.
“I thought I was coming for just two or three years to get clear of my medical school debts and go back to Africa,” Howe says. “But I really loved it here.”
Howe also serves as a chief clinical consultant in obstetrics and gynecology for IHS. In this role she helps review facilities and assists doctors with complicated cases at more than 40 OB-GYN practices. She also provides Advanced Life Support in Obstetrics training to clinic staff in the event that a patient can’t make it to a hospital in time.
The work has become increasingly challenging, as declining birth rates, rising costs, and funding issues have forced many tribal hospitals and clinics to close their childbirth centers—or to shut down entirely.
The situation isn’t unique to IHS. Nationally, more than 70 of the country’s 2,000 rural hospitals have closed in the last six years, and more than 600 remain at risk of closing, according to Becker’s Hospital Review, a publication for hospital business news and analysis.
Lara Shore-Sheppard, a professor of economics at Williams who studies Medicaid, says there’s been a move away from providing health care in hospitals.
Surgeries that once required an overnight stay are now outpatient procedures—a result of cost cutting and technological improvements, she says. And procedures such as X-rays and ultrasounds have moved from hospitals to primary care offices and small clinics. That puts financial pressure on hospitals, causing many to close, which forces patients in rural areas to travel farther for emergency services, surgery, and specialized treatments.
“With fewer people staying overnight, you have lower reimbursement, but you still have all the fixed costs of running a hospital,” says Shore-Sheppard, who serves on the board of Southwestern Vermont Health Care, which runs a 99-bed hospital in Bennington, Vt. “From a financial perspective, it’s challenging–and the more rural you get, the more challenging it gets.”
MAKING CARE ACCESSIBLE
It’s not uncommon for residents of Navajo Nation to drive several hours to receive medical care at Shiprock—and that’s when they have access to a working vehicle or the rain hasn’t washed away dirt roads.
“We try to stay flexible,” Kovich says. “If someone has hitchhiked for two hours, and they show up late, we’re still going to see them.”
But in rural Alaska, where tiny communities are scattered across islands and other areas without roads, some patients might never visit a hospital or clinic for routine care. That’s where Schwartz, a pediatric specialist, comes in.
Schwartz wanted to be a doctor since childhood, but at Williams she majored in American studies with a concentration in environmental studies.
Active with the Williams Outing Club, she traveled to Alaska soon after graduation to do environmental advocacy work and spent a number of years with the Juneau School District. But she couldn’t shake the dream of a career in medicine, so she earned a post- baccalaureate/pre-medical certificate from Bryn Mawr College and then a medical degree from Harvard Medical School in 2000.
After serving as a pediatrician with Seattle’s Department of Public Health and in private practice, she returned to Juneau in 2007 to work for the city’s largest medical clinic. ere she was one of seven doctors caring for 6,800 residents and was program manager for Alaska Emergency Medical Services for Children. In 2013, she began working in her current job with the Southeast Alaska Regional Health Consortium as the only provider whose sole role is traveling to remote communities to provide care.
“I have a tough time figuring out how to navigate these different systems, and I’m a doctor,” Schwartz says. “Part of my job is to empower families with limited resources to get the care that we all take for granted.” —Marna Schwartz ’87
Though Schwartz no longer sees the same volume of patients day to day as she did as an urban doctor, “I get to deal with much more complexity on a regular basis,” she says. “Sometimes in medicine you have to pick and choose what you work on, whereas I get to bundle a lot of things and treat them together. Someone might come in for one issue, and during the visit I’ll notice others.”
Schwartz specializes in treating autism and fetal alcohol syndrome—a particular problem in Alaska, which has twice the rate of alcohol dependence and abuse as the national average. Alaskan Native Americans, in particular, are disproportionately affected, according to the National Alcoholism Center.
Treating patients in their home communities provides Schwartz with a holistic view of their health. She usually spends between a half hour and an hour per visit, gaining an understanding of children’s lifestyles, daily routines, and support networks.
That’s a long appointment, considering that, as healthcare has become more specialized, the median length of an office visit with a primary care provider in the U.S. is about 15 minutes, according to Health Services Research. Complex cases are referred to a specialist.
In rural communities, however, specialists are hard to come by. According to the Rural Health Association, rural areas average 40 medical specialists per 100,000 residents, compared to 143 in urban areas.
“If you don’t have as many people in a population, you’re not going to have as many specialists on hand,” says Shore-Sheppard.
And that makes finding adequate care more difficult. A medically complicated child in Schwartz’s care might need to see three different specialists at a large pediatric hospital in Seattle. Those visits would need to be coordinated into a single trip because it takes the family a day to travel there and a day to get back.
“I have a tough time figuring out how to navigate these different systems, and I’m a doctor,” Schwartz says. “Part of my job is to empower families with limited resources to get the care that we all take for granted.”
She says the rewards of her work outweigh the frustrations. Schwartz vividly recalls examining a teenager who told her he was in excellent health. As the exam went on, she learned that his house had burned down, he was living with his grandmother, he had a heart problem when he was younger, and he had suffered from fetal alcohol syndrome.
“I asked, ‘Any problem with your joints?’ and he said, ‘No, well, other than my prosthetic limb,’” Schwartz says with a laugh. “That’s resilience. And that’s the kind of richness and complexity that happens in my visits.”
MORE THAN MEDICAL CARE
Like Schwartz, Martin routinely bucks the national trends for time spent with patients—both in the office and through other means. He might spend an hour with a patient rather than refer him to a specialist, knowing the patient likely can’t make the 22-mile trip to Worcester or 70-mile trip to Boston. He’ll stay late to accommodate those who can’t come in during the day, and he’ll communicate remotely with those who can’t get in at all.
During a recent tour of the Barre Family Health Center, he pulled out his smartphone to show a visitor a text he’d received from a patient over the weekend. It included a photo of an angry pink lump on the patient’s elbow that turned out to be an abscess. Even though Martin received the message late at night, he urged her to come to the clinic right away so he could treat the wound.
His care extends beyond the medical. “Getting electricity turned on for someone is just as important as prescribing medication,” he says. “Sometimes it’s more important.”
Martin majored in English at Williams, where he was co-president of the junior advisors. Though he was accepted into the Medicine in the Humanities program at Mount Sinai Medical School in New York, he instead earned his master’s degree in education at Harvard.
He taught for several years in Texas and Boston before attending Harvard Medical School through a program that forgave his debts if he practiced in underserved areas. After earning his degree in 2002, he spent two years working in rural Franklin County in Massachusetts and another two working at Federal Medical Center, Devens, a federal prison in central Massachusetts. He was appointed to the faculty at University of Massachusetts Medical School and began working in Barre in 2009.
One issue he’s addressing there is teen pregnancy. Nationally, the teen birth rate is nearly a third higher in rural areas than it is in more populous regions. At the same time, the teen pregnancy rate has been slower to decline in rural counties, according to a study by the National Campaign to Prevent Teen and Unplanned Pregnancy.
At Quabbin Regional High School, which serves Barre, sexual health education was lacking. And the nearest Planned Parenthood was in Worcester, virtually inaccessible to teens. So Martin set up a confidential system in which teenage girls could talk to providers about birth control—with procedures in place so their parents wouldn’t be billed. (Massachusetts law allows minors to obtain birth control without parental consent.)
Martin is also addressing the toll that heroin and prescription opioid abuse has taken on the region. e epidemic has grown in the last five years, and the number of overdose deaths in rural counties nationwide is 45 percent higher than those in more populous counties, according to the Centers for Disease Control.
In Barre, Martin says, the health center was overrun by people illegally seeking pain medications or treatment for addiction. Meanwhile, their loved ones were suffering from associated stress-related ailments. “People are so intimately affected,” Martin says. “ the degree of separation is one.”
He became one of only 4 percent of doctors in the state—and 3 percent in the U.S.—legally allowed to prescribe Suboxone, a combination of the drugs buprenorphine and naloxone that helps curb cravings for opioids without producing a high.
Martin also brought in counselors and built a lab to test for common side effects of addiction, including hepatitis C and cirrhosis. His efforts earned him an award in 2013 from the federal Substance Abuse and Mental Health Services Administration, which applauded him for his “quality and excellence in patient care.”
Often assisting in this work are students in the Rural Health Scholars Program, which Martin co-directs. The program, created by University of Massachusetts Medical School in 2000 and partially funded by the state, provides faculty mentors for roughly a dozen medical and nursing students. In addition to offering elective courses, the program helps place students in clerkships and residencies in rural settings around the country, runs intensive workshops on suturing, wilderness medicine, and X-ray reading, and provides stipends for summer research and community service projects. If, after they complete their training, the students practice in rural Massachusetts, their medical and nursing school loans are forgiven.
Among Martin’s students have been Kayla Elliott ’10, who practiced for a year in Barre; Blair Robinson ’13, who studied homelessness and opioid addiction on Martha’s Vineyard; and Lisetta Shah ’06, who’s now a resident at UMass Memorial Medical Center in Worcester and in Barre, where she works in the Suboxone clinic. “It’s a really rewarding part of what I do,” Shah says of working in the clinic. “People are getting their lives back together who maybe six months ago were kicked out of their house. Now they’re getting a job and stable housing.”
The word “rewarding” comes up a lot when Ephs providing rural healthcare describe their work. Back in Martin’s office, he points to a shelf filled with pickles and preserves given to him by an appreciative farmer he treated. He then sorts through his mailbox and pulls out a high school senior-class photo from a patient and reads aloud the inscription on the back: “‘Can you believe it? You’ve watched me grow from an awkward, shy 11-year- old to an 18-year-old college-bound graduate. Thank you for taking such great care of my grandparents.’” Martin looks up. “I mean, that’s what it’s all about,” he says. “It’s about being part of a community, and adapting to what people need.”
Big Solutions for a Small County
Berkshire County in Massachusetts has pockets of wealth, but the region struggles with the same challenges facing all rural areas. Many in the region are finding innovative ways to provide medical care.
“The strength of the community is important to the strength of the college,” says Jim Kolesar ’72, assistant to the president for public a airs at Williams and a member of the board of Berkshire Health Systems (BHS), which runs a 302-bed teaching hospital in Pittsfield. “One important strand in the strength of the community is the availability of quality healthcare.”
In September, Williams President Adam Falk sent an email to alumni in health professions, highlighting the shortage of providers in the region and asking the to spread the word about working here. Within a week, the college received more than half a dozen queries, Kolesar says.
Among the difficulties of recruiting and retaining providers are the underlying economics of the health insurance system. Residents of rural communities are older, less healthy, and more economically disadvantaged than those in cities and suburbs. They’re more likely to be insured by Medicaid, which serves the poor, or Medicare, for the elderly and disabled. Because these federal programs reimburse healthcare practitioners at lower rates than private insurance—roughly 60 cents on the dollar for Medicaid and 80 cents for Medicare—providers must take on more patients to make ends meet.
To offset the difference in reimbursement rates and entice more doctors to practice in the region, BHS is paying subsidies to medical practices.
“We incur the loss, but the loss is less than if we had no doctors,” says David E. Phelps, president and CEO of BHS.
BHS is also making its practices more e cient. When North Adams Regional Hospital closed in 2014, BHS took over the facility and restored many services, including the emergency department, physician practices, and outpatient surgery. Last year, with a $3 million grant from the Massachusetts Health Policy Coalition, it launched “Neighborhood for Health” to coordinate care for chronic conditions and preventive medicine.
Southwestern Vermont Health Care has taken a different approach. With a state-funded grant from the Vermont Health Care Innovation Project, it hired transitional care nurses to visit elderly patients after they’re discharged from the hospital to ensure they follow through with their care. Since the program’s inception three years ago, the number of patients visiting the emergency room has dropped by 40 percent, and hospital stays have decreased by 70 percent.
Meanwhile, individual providers continue to balance the rewards and challenges of working in a rural community. Kristin LaMontagne ’01, who grew up in nearby Peru, was a primary care doctor in Rochester, N.Y., before joining Williamstown Medical Associates (now Williamstown Medical of BMC) in 2011. She enjoys being able to work part time so she can spend time with her children. Yet she struggles to keep her patient load in check in this tightly knit community.
“I see people every day in the grocery store who hug me and ask if I can take them on as patients,” she says. “These aren’t faceless people you’re saying no to.”
—MICHAEL BLANDING ’95
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