There is an old saying that goes “A journey of a thousand miles begins with a single step”. It is as true now as it was when a Chinese philosopher first wrote it down about 2500 years ago. It means that any task, no matter how huge it may be in scale, importance or difficulty, starts the same way—with a first action that is taken. There is no fundamental difference between how you start out to walk across the room or across the world. You take a step. How many steps come after that and how hard those steps may be will certainly vary, but the beginning is the same. You take a step, then you take another. When you stop depends on how far you want to go.
So why am I telling you this? I’m telling you because I propose that we, the people of our little part of western Kentucky, embark on a journey together. The journey I propose will be neither short nor easy, but I hope to convince you that the destination will be worth the trip. We’ve already taken a first, small step but this is a trip that we have to take together. We have to all see the final destination and agree that we will all get there together, using our individual strengths and abilities to help each other along.
I don’t know the circumstances of your life. I don’t know where you came from, who your parents were, or the experiences that shaped you into the person you are. Some of us were born with advantages and some with disadvantages. Some of us are happy and successful (defined by whatever parameters you care to use to define “success”), some of us are not. I don’t know how you live your life, nor would I care to judge. I would ask these question, though—are you living the life you want your children to live and is the world in which you are living all that you want it to be? I hope your answer to those questions is “no”. If it is not, then we have no common ground on which to stand from which we can begin our journey together.
My proposal is very simple–I think we can make our lives, our communities and our futures better. And by “we” and “our”, I mean everybody, no matter who they are or where they live in our region. I believe we can be an example of what rural communities can become. When I was a boy, there was still a big, blue sign spanning west Arch Street, announcing to all who passed that they were then entering Madisonville, Kentucky—“The Best Town on Earth”. We were, according to the sign, a Big Tobacco Market and the Heart of the Coalfield. I knew practically nothing about the tobacco market and only a little about the coalfield at my age, but I already knew that the rest of the sign was true. All through my childhood, I remained convinced that I really did live in the Best Town on Earth. Eventually, like most of my friends, I had to leave Madisonville after high school to do the kind of work I wanted to do but, unlike most of them, I didn’t really want to leave. I learned a great deal in the time I was gone, including that Madisonville wasn’t really the best town on Earth. I left in 1981 and was gone most of the next 35 years. I came home fairly often, though, and I was able to see Madisonville change in much the same way that an uncle who only sees his nephews once or twice a year sees them grow. If you see things every day, you don’t notice gradual changes, but if you only see them every now and again, you see the sum of gradual changes as big differences. The Madisonville of today is a very different place in many ways than the Madisonville of my high school days, and that goes for most of the rest of the county and our surrounding region. In fact, the same holds true for most of rural America.
Towns exist for a reason. Seldom did anyone just stick a sign in the ground in some random place and decide to build a town there. There was always a reason for the town, whether it was a crossroads, a railroad, a river port, a mine, a mill or something else. There was a reason why there needed to be a town built in a particular place. Madisonville was a farm market community when it was founded in 1807, but coal mining became the backbone of the economy in most of the region in the late 1800’s and remained so for the best part of a century. Coal mining employment, however, peaked in 1949 and coal production peaked in 1990. Kentucky coal production is down by about 75 percent from that peak, and employment is less than 10% of what it once was. Many communities in our region are now wondering what mining towns and railroad towns are supposed to do when the mines have closed, just as rural communities throughout the country are searching for relevance in an era when their main reason for existing has gone by the wayside. What is a company town to do when the company shuts down?
I think we can all agree that Madisonville and most of our surrounding communities could use some help. Our population is decreasing. Like most of rural America, our population is, on average, older than the populations of more urban areas, so the death rate is higher than the birth rate. To compound that, more people are moving away from our area than are moving to it. Many of our brightest and most ambitious kids have been leaving town for generations to build their lives in bigger communities where there is more opportunity. That leaves us with an aging population, and like most of rural America, our population isn’t just aging—it’s also poorer and less healthy than urban populations. That’s not a recipe for growing a vibrant community. We have two choices. One choice is that we do nothing to change that narrative and Madisonville and the rest of our region will continue on a long, slow slide into irrelevance. The other choice is that we do something about it.
Personally, I choose the second option, and I propose that we use improved community health and wellness as our starting point. First, let me say that there are good things already going on in our region. We have more community social events, beautification projects and charitable organizations, for instance, than I ever remember from when I was living here as a kid. That is great stuff, and we need more of it. What I propose in the way of change is something on a more fundamental level.
Poor health is a fact of life in Kentucky. We rank about 45th in the nation in overall health and wellness. I don’t want to go into detail on that today, but I will in some columns that will come after this one. Today, I just want you to realize that our health is very poor, it’s getting worse, and our health and our prosperity are directly linked. The good news is that we have the means to build a better future.
Ever since the first person decided to become a healer, people have gone to them when they were sick. Duh. That just makes sense, right? Get sick—go to the doctor. Our entire healthcare system was designed to support that process. It turns out, however, that that is not a very efficient way to take care of people. You don’t wait until your car breaks down to do anything to take care of it, do you? No. You change the oil. Rotate the tires. Have the brakes serviced. Everyone knows that you need to do these things to keep your car working. Yes, it will probably break down sometimes and you’ll need a mechanic to fix it, but if you do regular maintenance, you will certainly break down less often. Everyone knows that. So, why, do you suppose, everyone knows you have to maintain your car, but far fewer people apply that same logic to their own bodies? They wait until something goes wrong, then they go to the doctor to (hopefully) get it fixed.
Some genius has finally figured out that what we’ve always know about cars is also true about people. It is much better, much more efficient and much cheaper to help people stay healthy than it is to wait until they get sick to see them. The American healthcare system is starting to adjust to this new and obvious revelation. The entities that pay for most of our healthcare, which is insurance companies and the government, are now starting to reward healthcare providers for keeping patients out of the hospital, not just paying for their treatment when they get sick. Now we are interested in how to keep people healthy, and the thing is, being healthy isn’t just a better way to live, it’s also a lot cheaper.
So, we need to help people be healthier and help them stay healthier longer. Part of that answer is that healthcare providers need to work with their patients who have or are at risk for chronic (long-lasting) diseases to help them manage their conditions. Providers and patients should be partners in trying to make sure, for instance, that they manage their diabetes so that it doesn’t lead to complications. But here’s the kicker and here’s where the real meat of my proposal lies—it isn’t doctors and hospitals that are the biggest players in community health and keeping people healthy. It turns out that what we might call “traditional healthcare” is only about 20% of what determines health outcomes (outcomes being how long you live and how healthy you are). The other 80% contribution to health is what is often called the “social determinants of health” or, more precisely, the “socioeconomic determinants of health”. We’ll abbreviate that SDH. Included in SDH are people’s behaviors or choices—things like tobacco use, diet and exercise, alcohol and drug use and so on. How people live is also part of it—including education level, employment, income, and family support. Finally, the environment in which you live matters a great deal to health. Is your home a healthy place? Is your air or water polluted?
We are very fortunate around here in that we have an extraordinarily large and advanced healthcare infrastructure. Rural areas like our just don’t have the facilities and healthcare providers that we have. We’ve got that 20% (which is a really important 20%) in the bag. This is one big reason why I say that we can become an example of what rural community can be. We have resources here that most rural areas just don’t have. If anybody can do it, we can.
In my next post, I’ll tell you how I think we can get it done.