Many counties in America lack the number of doctors recommended by the U.S. government. The patient to doctor ratio should be no more than 3,500 patients to one doctor; however, many communities have far fewer.
By: Jill Riepenhoff, Daniela Molina, Jamie Grey and Lee Zurik
Originally Published: April 5, 2021
KENNETT, Mo. – It’s never easy raising a medically fragile child. But for some parents in this rural Midwestern town, it used to be a lot easier.
Kristie Carnett’s daughter Faith has cerebral palsy. Though she’s 22, “she’s the equivalent of like a 6-month-old. She can’t talk. She can’t walk, and she’s fed through a g-tube because she can’t eat by mouth.”
Sarah Bellomy’s 9-year-old son Hayden has Acute Flaccid Myelitis, what she calls a “one-in-a-million” polio-like disease that affects his spinal cord and has left him on a ventilator.
But when something went wrong, each mother took comfort that they had access to care that would keep their children alive and well.
There was a hospital, specialists and three pediatricians to help manage and care for the special needs of these children.
Then in 2018, the hospital closed and nearly all the doctors vanished.
But pediatrician Dr. Andrew Beach wasn’t among the physicians beating a path out of one of the poorest places in Missouri’s Delta region. He wanted to calm nervous parents.
He hung banner on the white pillars outside his Dunklin County office: “Dedicated to our patients! We are not leaving the area!”
He now is the only pediatrician in a county that is becoming a healthcare desert.
“When I got here, there were three (pediatricians), and we had a load of sub specialists,” Beach said. “We had a lot of different little things there, that are no longer here.”
Today, Beach sees 14,000 patients a year.
Though the federal government has not set an ideal doctor-to-patient goal for pediatricians, it has set a standard for primary care physicians. Those are family doctors, general medicine and internal medicine doctors who treat some children but mainly adults.
The federal government says those doctors ideally wouldn’t have more than 3,500 patients on their caseloads. Dr. Beach treats nearly five times that many children.
The residents of Dunklin County are lucky to have Dr. Beach.
In the Delta region, an area that stretches from Missouri to Louisiana and includes parts of eight states, more than half of its counties don’t have a pediatrician.
The American Academy of Pediatrics says that the number and distributions of primary care pediatricians “is inadequate to meet the needs of children living in rural and other underserved areas, and more . . . will be needed in the future because of the increasing number of children who have significant chronic health problems.”
The shortage of pediatricians is part of a looming national crisis: too few doctors to provide preventative care to adults, women, and children from coast to coast.
Across the country, more than a thousand counties have been designated by the federal government as a health professional shortage area because there aren’t enough primary care doctors to meet the demands.
In 207 counties in 2018, there wasn’t a family, general or internal medicine doctor – the primary care doctors mainly for adults, according to an InvestigateTV analysis of federal data on the number of doctors working that year.
Data Visualization: Jamie Grey, InvestigateTV
More than 40% of the counties in the U.S. didn’t have an OB-GYN doctor, leading to a lack of early detection of certain cancers and the lack of prenatal care that contributes to babies being born underweight.
For children, nearly a third of U.S. counties don’t have a single pediatrician, a primary care doctor specially trained for years to care for those under the age of 18.
The lack of access to regular health care can lead to a lifetime of problems for children and adults. Many residents in communities with too few doctors already suffer from obesity, diabetes, cancer and a host of other problems.
“All the health problems that we were loaded with here,” Dr. Beach said. “We have morbidity and mortality like nowhere else in the state. Our infant mortality rate is the highest in the state too. So, I mean, we have issues.”
The lack of doctors leads to long drives and heart ache
Erma Peterson lives in one of those counties without a primary care doctor.
In 1984, the federal government designated Issaquena County, Mississippi as a primary care doctor shortage area.
The lack of access to doctors proved costly to Peterson, 59, who has lived there her whole life.
“It’s really not for young people because there’s really nothing here to offer you,” Peterson said.
Nationally, 83 million people such as Peterson live in a primary care doctor shortage area, according to the U.S. Health Resources and Services Administration. HRSA estimates that 15,257 doctors are needed to eliminate the shortages.
But the need is particularly great in the Delta and Appalachian regions of the country.
The federal government has designated more than a fifth of the 662 counties in the regions as “high needs” counties because of the large percentages of vulnerable people who live there. They may be the elderly residents, or they may be the newborns, who struggle to make it to their first birthdays.
In February 2020, researchers from the Cleveland Clinic, UC-Davis and Sacramento State examined doctor shortages in 2017 and projected the need in 2030. They graded each state from A to F.
Thirteen of the 17 states in the Appalachian and/or Delta regions received Cs or Ds based on the number of doctors working there in 2017. By 2030, their scores will slip as doctors leave the areas.
- West Virginia, graded with a C, will need more than 1,000
- Louisiana, with a D, will need 4,820.
- Mississippi will score an F, with the need for 3,700 doctors.
Mississippi’s Issaquena County is a health care desert.
It hasn’t had a doctor, a nurse practitioner or a rural health clinic since at least 2010, federal data shows. The nearest healthcare provider is 15 miles from Peterson.
In 2013, Peterson learned just how far away she is from quality care when her husband, Milton, called and said, “I’m having a heart attack.”
“I didn’t really exactly know what was happening. He told me his stomach was hurting. He told me he needed to go to the doctor,” she said.
Mrs. Peterson drove him 15 miles to a small clinic in a neighboring county only to be routed to the nearest hospital in Vicksburg, about another hour’s drive.
As she drove, she repeated to her husband, “Hold on, hold on, Hold on.” She prayed she would be able to get to the hospital on time – and without speeding.
The heart attack ultimately proved fatal. Mr. Peterson died 14 days later. The lifelong farmer was 73.
Mrs. Peterson is realistic that a hospital can’t be found on every street corner like a chain pharmacy. But having easy and regular access to doctors is important in every community.
“Give everybody the same treatment,” she said.
She said she and their daughters have coped with her loss with “the help of the Lord.
“It’s been going on eight years. It’s still a hole in my heart.”
Women in rural areas struggle to find the specialized care they need
Cervical cancer is preventable, detectable, and easily treated if found. But in some areas of Appalachia, it often has been a death sentence.
In Kentucky, Ohio and Virginia, a higher percentage of women who live in those states’ Appalachian counties develop cervical cancer compared to residents who don’t live in the region, according to data from the Appalachian Community Cancer Network.
In Appalachian Kentucky and Ohio, the percentage of women who die from cervical cancer is nearly 20% higher than those who don’t live in the region.
The lack of access to an OB-GYN contributes to the disparities, say Drs. Mark Dignan and Electra Paskett, researchers with the Appalachian Community Cancer Network, a National Cancer Institutes-funded project to research solutions.
“If you have people that don’t have access to health care, then they wind up having worse outcomes,” said Dignan, who also is a professor at the University of Kentucky College of Medicine.
More than 60% of all the OB-GYNs in 2018 were clustered in the country’s 140 most populous counties.
Across the U.S., nearly half of counties didn’t have an OB-GYN, leaving some 10 million women without access to specialty care during pregnancy and regular cancer screenings.
Data Visualization: Charles Minshew, IRE for InvestigateTV
To help erase the cervical cancer disparities, Dignan and Plaskett are training nurses and primary care doctors in 50 rural health clinics in central Appalachia how to teach prevention to their patients.
The solution seems simple: vaccinate teenagers to prevent HPV, a virus that is a leading cause of cervical cancer; perform regular pap smears; and help women stop smoking.
Rural health clinics are often so busy because they are the only healthcare provider in the county and typically focus more on treating the immediate medical concern rather than prevention, said Plaskett, who is a professor at The Ohio State University College of Medicine.
But, she said, the cervical cancer prevention project is working. Doctors, nurses, and even receptionists are convincing their patients to be vaccinated and screened.
Historically, Appalachian residents “haven’t seen examples of people successfully beating cancer. Because in their communities, people get cancer and they pass away,” Dignan said. “One of the things that I’m passionate about is increasing people’s sense of, ‘I can beat this, this is something that can be dealt with.’ So, what I’m focused on is helping or trying to give them the tools to be able to make that a reality.”
The lack of OB-GYNs also contributes to babies being born not weighing enough or dying before they turn one – problems that have hit Appalachia and the Mississippi Delta regions especially hard.
In the regions’ counties with higher-than-average rates of babies born weighing less than 5 ½ pounds, more than 70% of them don’t have an OB-GYN.
Lewis County, West Virginia and Mississippi County, Missouri lead the nation in the rate of babies who die before their first birthdays.
Their infant mortality rate is more than triple the national average. Neither county has an OB-GYN.
It’s a similar story in pediatrician Dr. Beach’s county.
“The closest obstetricians are 40 minutes to over an hour,” he said.
Pediatricians have left a void in Appalachia and Delta
Kristie Carnett and Sarah Bellomy now know a lot about driving for medical care for their children since the hospital in their town closed three years ago.
Carnett takes Faith to the children’s hospital in St. Louis to see pediatric specialists. It’s a 3 ½-hour drive.
Bellomy drives to Memphis, a nearly two-hour drive.
In the meantime, both rely on Dr. Beach to keep their children healthy so they can avoid unplanned and emergency visits so far from home.
Both mothers credit Dr. Beach with saving their children’s lives and trusted him when he said he wasn’t leaving the community.
“My heart was in rural medicine to start with. I actually have a PhD in cancer research as well. I originally intended to become a pediatric oncologist, but I spent some time training with a set of doctors in Frankfort, Kentucky, and just changed my whole perspective, taking care of the kids in the community seemed more important to me,” Beach said. “And so I started, and I never left.”
More than a quarter of the 662 counties in the Appalachian and Delta regions lost pediatricians between 2010 and 2018, federal data shows.
Nearly three dozen counties were left without a pediatrician, leaving the care of children to primary care doctors who treat both adults and kids.
Data Visualization: Charles Minshew, IRE for InvestigateTV
“No offense to family practitioners, they fill special void, but they’re not pediatricians,” Beach said. “The training is completely different. There’s a lot of things that only a pediatrician would think of. . . We do three-year residency exclusively in pediatrics, which includes critical care, and they might do three to four months.”
Childhood obesity is a particular issue in Beach’s Dunklin county.
More than a quarter of children are obese, and another 39% are overweight, state data shows.
It’s a “horrible problem here,” Beach said. “And it definitely got worse during COVID. A lot of people put on a lot of weight.”
Weight problems in childhood can lead to chronic diseases in adulthood such as diabetes, and the lack of pediatricians exacerbates the problem.
“It’s difficult to recruit anybody here, just because there isn’t much to offer,” Beach said.
The industries are largely gone, the schools aren’t top-tier districts and there’s little for kids to do outside of playing sports.
A few years ago, a new pediatrician arrived in the county. She didn’t stay long, Beach said.
“It’s a simple country town. I mean you have to be able to communicate, and that just wasn’t her forte,” he said. “You have to fit in.”