Like I said in my last post, I’ve spent several months staring at county health data. Countyhealthrankings.org has become my de facto homepage. And in that time of poring over numbers and statistics, I fell into a stereotypical mindset that I think is pretty common for Virginians. The picture in my mind was of a healthy Northeast, while us down in the Southwest were the sickly backyard of the Commonwealth. So I was surprised by the actual map of the 2016 rankings (above). Looking at the lightest localities, the top 25% performers for Virginia, the pattern isn’t nearly so clean cut. Sure, there’s a large cluster in NOVA. But there are also 3 counties, Roanoke, Botetourt, and Bedford, right up 81 from us that seem to be breaking the mold of our stereotype. I also spent a while wondering about the odd diagonal of health that snakes up from the Atlantic, finally realizing it is the course of James River. These three regions point to one of the simplest factors in health: money. The James River, with its historical role in plantation-era trading, and the Roanoke Metro area, a long time railroad hub, have been sites of extended economic stability. The same goes for NOVA. But the effects of poverty and wealth on the presence of death are only one foundational factor. I wanted to dig deeper. You can view all the data I collected here.

Before we do that, though, I think it helps to see where Pulaski County falls in these rankings. Of all localities (counties and independent cities) in Virginia, we ranked #85 in 2016. This rank puts about 63% of other places in the commonwealth ahead of us. If we marked off the quartiles of Virginia localities, Loudoun County ranks as the top 1%, Henrico County at 25%, Franklin County at 50%, Radford City at 75%, and Emporia City at the bottom of the list.

63% puts us squarely in a category of “below average”. Note that Pulaski County is not the worst. And in fact, we have improved dramatically in just 5 years, compared to 2012 when we fell in the bottom 10% of counties. We also rank above Radford, which could be reason to toot our “Battle of the Bridge” horn. But the comparison fell apart when I realized that over 50% of the Radford population is the student body of the university. This weighs in negatively on their health outcomes, with more smoking, STDs, and violent crimes. But it also gives them a lower rate of premature deaths as graduates move away each spring and new classes of young, healthy students arrive each fall.

Below Average

Previously I pointed out how high our premature death rate stands. And the combination of poverty and ranking “below average” leaves many of our other rankings unsurprising on their own. Pulaskians, compared to the average Virginian, had:

• 20% higher rates of obesity, diabetes, and physical inactivity
• 20% more spent on healthcare costs
• Significantly higher rates of children living in poverty and teen births
• Twice the likelihood of dying of drug overdose
• 70% greater likelihood of dying from accidental and self-inflicted injuries
• 40% greater likelihood of dying in a car crash.

The level of care provided to our citizens is also sub-par for Virginia. Compared to the state average, we had:

• 30% fewer primary care physicians
• 60% fewer dentists  (9 serving a population that, on average, might require 22)
• 78% fewer mental health providers (only 10 serve within our county)
• 70% fewer nurse practitioners and physician assistants providing primary care services (7 within Pulaski County)

And more concerning than that lack of providers is the amount of time our citizens spent hospitalized for conditions that could be handled with regular primary care. We had 80% more preventable hospital stays for COPD, diabetes, asthma, hypertension, urinary infections, and dehydration than the state average.

Reading statistics about our county’s ranking only gives part of the whole picture, though. In a state as diverse as ours, digging deeper means seeing how we compare to those most like us. So I took two sets of localities to compare our data with: our direct neighbors (Bland, Carroll, Floyd, Giles, Montgomery, and Wythe Counties, along with Radford) and the nine other counties in the state with similar populations (20-45,000) and rurality (40-65%) (Fluvanna, Isle of Wight, Warren, Prince George, Orange, Amherst, Prince Edward, Wise, and Tazewell Counties). In both groups, Pulaski is still below average, but the degrees of variation differ from the statewide view. Both groups shed some light on which of the health issues we face are specific to our end of the state, which are problems for all small towns, and which are particular to Pulaskians.

Where Do We Fall?

Let’s start with the big one: premature deaths. Compared to the state average, we lost 50% more lives prematurely in Pulaski County (450 per 100,000 vs 310 per 100,000), with 50% more years of life lost (9,200 years of life per 100,000 vs 6,100 years of life). Among both our neighbors and the 9 similar counties, we were only 10% higher than the average on each. Bland, Wise, and Tazewell each reaches over 10,000 years of potential life lost. Our rate of obesity, diabetes, physical inactivity, and healthcare costs are all slightly above the average compared to the counties around us. We actually have a smaller percentage of children living in poverty than our neighbors. Deaths from injuries and drug overdoses are about the same regionally, and we have a lower rate of deaths by motor vehicle. And when it comes to care, we are about on level with our neighbors for physicians and dentists, with more mental health providers. Unfortunately, we have the highest rates of HIV and teen births regionally. We still lack in NPs and PAs. And our number of preventable hospital stays is 40% above the average among our neighbors. This is all similar to our comparisons with the 9 other counties like ours across the state, though we paradoxically have the 3rd fewest incidents of HIV.

Many of these figures and comparisons highlight how our geographic and economic differences play out in real life. The most obvious example is the care we are able to receive. In our region, Floyd and Montgomery County both rank above average. Not only do they share easy access to Carilion and Lewis Gale hospitals in their own neighborhood, but they’re a much shorter drive to the even larger, better equipped Roanoke branches in those same systems. Fluvanna, Isle of Wight, Warren, Prince George, and Orange Counties have median household incomes much closer to our state average and happen to sit closer to metro areas with needed medical services available. How does this play out for a disease common to all of these counties, like diabetes? Depending on where you live, your ability to receive specialized care shifts drastically. Fluvanna and Isle of Wight Counties have access to Sentara Hospitals, which employ 33 endocrinologists across the East Coast of the state. But if a patient in Tazewell or Wise (or even Pulaski) goes to their regional hospital, they’ll need to get an appointment with one of a handful of endocrinologists in Roanoke or cross the state line into Tennessee. Eventually, the inability to receive regular care for a very treatable disease lands our people in the hospital 3 times as often as Virginians with closer access.

The way death affects us in small towns and counties is obviously complex. It’s a mix of geography, economics, and demographics that is hard to untangle. And as we will see next time, this has national repercussions. But I hate to leave us on a low note, so let’s take one last look at the numbers. Pulaski has 40% more opportunities for social association (clubs, churches, professional organizations, and athletic centers) than most counties in the state, decreasing our risks of social isolation, which is a factor as strong as smoking in most morbidity studies. And both regionally and in the state, we have much lower levels of racial segregation than most counties. This factor is linked to a better sense of how our community looks and more sympathy to the problems we face together.