In the digital age, telehealth should be a no-brainer, especially in rural areas where distance makes a difference in access to care. But barriers have slowed adoption by doctors and patients. In North Carolina, telehealth enthusiasts are looking for some help from the legislature to lower some of those barriers.
Photo by Rose HobanSheila Davies, former director of telemedicine at Albemarle Hospital in North Carolina, demonstrates how the telepsychiatry unit functions.
Editor's Note: This story first appeared in North Carolina Health News and is reproduced here with permission.
When Cody Hand’s 3-year-old daughter fell and chipped her front tooth, he took her to the emergency department at WakeMed Hospital in Raleigh, North Carolina But the doctor there was unsure what to do about her tooth, so Cody dialed up a friend who’s a pediatric dentist.
The doctor, dentist and Hand then did a FaceTime consult on Hand’s iPhone.
“It was a non-secure link,” said Hand, who happens to be the vice-president for governmental affairs for the North Carolina Hospital Association. “But that was OK with me. It was just a dental issue.”
“But it shows how telemedicine can work,” he said.
In many ways, most of the U.S. is behind the curve on using telemedicine. In the developing world, doctors have been doing X-ray consults via smartphone for years and the Native Health Service in Alaska has been using a form of telemedicine since the 1970s, when the NHS provided satellite hookups to every remote clinic in a Native village.
In North Carolina, telemedicine remains a health care resource that’s been underutilized. But it looks as if that might be changing. A telepsychiatry program is in the process of scaling up statewide after a successful pilot. More hospitals and more providers are getting wired to do things like stroke care from a distance, and the costs of getting set up are coming down.
But there are still roadblocks to widespread acceptance by physicians. That’s why telehealth leaders were at the North Carolina legislature last month – to ask for some help.
All photos by John TullyTrip with Libby and Catherine to Cannon Mountain in Franconia, NH. Clouds covered everything south of Franconia Notch. The notch was socked in with clouds.
Photographer John Tully moved around a lot growing up. As the child of a military family, Tully lived in five different states before entering college. These frequent moves meant that Tully often felt like an outsider, never fitting in to the communities he’d inevitably leave. His series Smalltown Landscapes explores what Tully imagines his life might have been like if he’d grown up in one place.
Cleaning the roller coaster at Santa's Village. Jefferson, New Hampshire. 2011.
Daily Yonder: Where did you grow up? Tell us a little bit about your background.
John Tully: If I could, I’d say I’m from Bethlehem, New Hampshire, in the heart of the White Mountains. That is always the constant place where I return throughout my life. It’s a small town with a blinking light at the intersection with roads that lead on to mountains, to forests and rivers, and to so many memories. I guess a more accurate answer is I am a "military brat." But that’s kind of like writing off a lot of transitions that have shaped my life to this point. That’s the abbreviated version. I’m not sure where I’m from so much as where I’ve lived: Massachusetts, Rhode Island, Virginia, Hawaii, California, back to Virginia, college in Missouri, Denmark, Pennsylvania, Washington D.C., Michigan and New Hampshire.
Swimming hole on the Ammonoosuc River. Twin Mountain, New Hampshire. 2013.
DY: Where do you live now?
JT: I live about a mile from the ocean on the shifting sands of the Outer Banks in North Carolina. For those who are unfamiliar, the Outer Banks is a chain of barrier islands on the eastern coast of North Carolina. We moved here a year ago after I got laid off from a newspaper and my girlfriend and I were ready to make some changes while quietly focusing on photography.
In partnership with the Canterbury Historical Society, Canterbury Elementary School students spend a day at the one-room school house in the town center. Students were encouraged to dress similarly to the time period. During recess, they played games from 1800's. The one room school house in Canterbury was built in 1844 and was last used in 1955.
DM: When did you first start taking pictures?
JT: I started with photography back in high school. In English class we had a project to shadow someone at a profession we thought was interesting. Photography seemed like a way I could experience the world so I wrote to a few publications in the D.C. area. My local newspaper was the one to extend an invitation. I was 14 at the time and they invited me to keep going back, so I did. When I got my license I was on my own covering assignments. I look back at my introduction being more about learning the technical, composition, light, instead of learning people.
My perception of photography has almost done a 180 since. I went through a phase where I thought photography could make a difference and that there was a definitive truth. Like so many others, I followed a path set by people before me: go to college, study journalism, do internships, enter contests, do workshops, learn, graduate, work at small newspapers, cut my teeth, move up. Routine. Security. Predictability. So I thought. Back then, my ultimate goal was to be a foreign correspondent. The world has changed. I have changed. I graduated college in 2008 right when newspaper layoffs were becoming rampant across the industry. I managed to dodge them for about five years.
An early book on community-development practice shows where the field started – and how far it has come. A century ago, it was the first book use the words "community development" in a title. It certainly wasn't the last.
Frank Farrington’s Community Development, published a century ago, is recognized as the first book to use the term in its title.
It’s safe to say that whenever you have a group of humans living together in a place, you have some sort of community development going on. For most of our human existence, however, we never called it that.
History tells us that early colonists of the budding United States practiced various forms of community building, such as establishing governments, schools, libraries, and churches, building markets and roads, and even trying to attract businesses. During the 19th century, village improvement and beautification movements emerged, especially in the Northeast.
Farrington’s century-old approach to community development focuses on starting a business man’s group to do community projects. It is a virile (a word popular at the time), mostly top-down approach to men’s business. The village improvement society, led by women, is the handmaiden of the business group, important, but secondary to building wealth.
Agricultural technology comes in all sizes – from a big, new harvester to a tiny genetically modified seed. Labels are supposed to help consumers keep track of what's in their food and how it is produced. But do we even know what we’re reading?
Daily Yonder illustrationIf only farmers had technology like this.
“Is that gonna help you grow more corn?”
He was talking about my new 1985 model MS DOS 186 desktop computer.
He sniffed at my computer because of all the hype surrounding computers back then, and the fact that people can be sold a bill of goods only to learn later there’s more to it than that.
The computer helped me do things I was already doing – like bookkeeping and word processing – only faster.
But it didn’t make me a better farmer.
Times have changed since then. Unfortunately a lot of other things haven’t. Today’s mobile phones are more powerful than my first computer. Most of the farm tractors and trucks I own won’t run without their electronic brains. But while electronics play an almost irreplaceable part in modern-day farming, production basics all begin with the simple act of placing seed in soil.
Though not as fast, I can still do that with my bare hands.
About 10 years after my first computer was built, technology came to seeds in the form of genetic modification. Most farmers were quicker to adopt technology in their plants than in their tractor cabs. Like farm equipment, seeds all start out with a few basic components the origin of which go back to basics.
Corn is still corn and horsepower is still horsepower.
Though losses could be unpredictable due to weather or other circumstances, farmers saw value in plant modification immediately when ears of corn ceased being sheared from the stalks by little larvae called European corn borers. As borers ate, ears fell to the ground, gone to all but scavenging livestock because no farm machine built to date can collect them.
Technology has come only so far.
GMO corn killed corn borers with their first nibble, before they could bore through ear shanks. The trade off in that came with tech fees paid to patent holding seed companies, and the transfer of a unique protein, borrowed from a certain bacteria that ate through the gut of corn borers as they ate through the corn.
After learning to make biofuel to use on his own farm, John Williams has expanded his business to help others create their own energy. For Williamson, there’s a diversified income stream. For his neighbors, there’s new access to renewable energy.
Photo by Vermont Bioenergy InitiativeJohn Williamson, the owner and operator of State Line Farm Biofuels in Shaftsbury, Vermont, began processing his own biofuel in 2004 by experimenting with sunflowers, canola, mustard and flax seed.
Now he’s helping other farmers in his region make the transition to biofuel by sharing his knowledge and production capacity. Instead of producing just his own fuel, he’s helping others with biofuel production services.
He says his facility is “like a train that people can get on and off at any point along the process – at any station.”
State Line Biofuels operates a 300-gallon batch oilseed biodiesel production facility, providing biofuel and livestock meal for on-farm use. When he’s not processing his own biofuels, he offers various services that go into making different forms of biofuel. One farmer may take seeds to State Line to be cleaned, dried, or pressed. Someone else might want to convert used cooking oil into biodiesel. This open model creates more opportunities to do business and to diversity his income.
State Line Farm Biofuels provides combine (harvesting) services to nearby farms such as Clear Brook Farm and True Love Farm. They have even helped to harvest pennycress, an experimental oilseed crop for Tiashoke Farm in Easton, New York.
State Line presses oilseeds for each of these farms as well as Lawes Ag in Brandon, Vermont, and Wood’s Market Garden in Brandon, Vermont. Williamson also receives unique pressing requests for smaller scale producers, including soybeans for a sheep farm in Massachusetts and safflower for a cosmetics company in New York City. The biodiesel processing equipment is used to make fuel for most of these and several other farms and also presses oil for food products.
State Line Farm Biofuels strives for a closed-loop system, meaning that all inputs are sourced from the farm and all outputs are recycled into the process or elsewhere on the farm. “We take a long view on biofuels while remembering simplicity, re-use and self-sustenance have a long history on Vermont farms,” Williamson said. “A hundred years ago all farms were growing their own fuel.”
One of the most urban states in the nation has just created a rural policy advisory commission. We asked a rural Massachusetts political strategist why the Bay State needs the new body. It all starts with a governor who didn’t pay enough attention to rural, says Matt Barron.
Cultural activities are an important part of the rural economy in Massachusetts. Each year the Jacob’s Pillow Dance Festival attracts thousands to its western Massachusetts home in Becket.
A new state commission in Massachusetts will look for ways to improve economic and social conditions for rural parts of the commonwealth.
Governor Charlie Baker signed the Rural Policy Advisory Commission into law early this week as part of the 2016 state budget.
Less than 10 percent of the Massachusetts residents live outside metropolitan counties. That's one among the lowest rates in the nation. But there are still significant rural regions that contribute to the state’s culture and economy, says Matt L. Barron, a political and rural strategist who lives in the Hilltowns of rural western Massachusetts.
We asked Barron to tell us more about rural issues in Massachusetts and explain the need for a rural policy commission. He said the commission grew out of dissatisfaction with how the governor treated rural areas during and after his 2014 campaign.
Daily Yonder: How do rural politics, culture, and economy play out in Massachusetts? Where are the key rural parts of the state? Are they cohesive politically? Are they strong enough to be a presence in the Capital?
Matt Barron: The Bay State is the third most densely populated state in the nation behind New Jersey and Rhode Island, but like every state, we have rural areas and towns. The most rural areas are western Worcester County and Franklin County along with Hampshire and Berkshire counties in the central and western part of the Commonwealth. The islands of Dukes County (Martha’s Vineyard and the Elizabeth Islands) are rural, as are parts of southeastern Massachusetts and Cape Cod.
We have “blue rural” and “red rural” with the blue being mostly in western Mass and the red being in Worcester County and in the cranberry bog communities in the southeast.
While the state is dominated by an urban and suburban power structure in the Legislature, we have a new Senate president (Stan Rosenberg – D-Amherst) who is from the west who represents some very small towns. And we have some some key House members from rural districts, like Stephen Kulik, D-Worthington, who filed this legislation creating the Commission. People like these are are in leadership positions, and they serve as equalizers on budget and policy matters than can be viewed as threatening to rural constituencies.
DY: Are there big economic differences or disparities between rural and urban Massachusetts? What are the key issues facing rural Massachusetts?
MB: There is an east-west economic divide across the state with Boston and many of its immediate suburbs doing very well with good jobs and the western part of the state and much of southeastern Massachusetts doing poorly. Housing prices are much higher in the Boston area and they have robust sectors in high technology, biotech and life sciences and financial services that don’t exist much in the hinterlands. Rural Massachusetts is much more dependent on tourism, the “creative economy” (arts and culture), agriculture, fishing and forestry and manufacturing. Around the urban centers and university towns in western Massachusetts, jobs in higher education and health care are key.
One of the biggest issues facing rural Massachusetts is the lack of high-speed Internet access. Wired West, a co-op of small towns, is now working on funding to build-out the “last mile” rural broadband to homes and businesses. You can’t sell a house in rural Massachusetts without fiber optic-level broadband no matter how nice the view or how good the local school system is.
The opioid crisis is very real in many rural towns where jobs are few.
We are also fighting newly proposed natural gas pipelines that aim to bring fracked gas in from Pennsylvania across working landscapes such as farms, orchards, woodlands and environmentally protected natural areas. Massachusetts is dependent on natural gas for about two-thirds of its power and many feel we should not become even more dependent on a single fuel source. There is also great worry and concern that rural Massachusetts will become despoiled so that the gas can be exported from the Canadian Maritimes, overseas to Europe where it will fetch a higher price than here at home. Other issues are ones of equity, such as getting the maximum amount of state funds for regional school transportation reimbursements and payments in-lieu of taxes (PILOT) for state lands (mostly huge tracts of state forests, parks and wildlife management areas that are hosted by rural towns but are off the tax rolls, hurting our ability to do rural economic development and grow our tax bases).
Photo via the Boston GlobeBerkshire Farm & Table is a nonprofit that promotes and highlights the Berkshire's food culture.
DY: What is the new rural policy commission? What do you hope it can accomplish? Why is it necessary?
MB: The commission is an advisory group of 15 members, mostly people from regional planning commissions in the counties or areas that have rural communities within their jurisdictions. The governor, House speaker and Senate president get to name the balance of the membership and everybody “shall be persons with a demonstrated interest and experience in advancing the interests of rural residents,” as per the enabling legislation. Hopefully, if we can get an all-star group of appointees, we can work with the Baker administration to head off proposed rules, regulations or initiatives that could be hardships for rural constituencies to comply with. On the flip side, there are opportunities in areas such as food and culinary tourism and green energy such as combined heat-and-power systems for rural schools and municipal buildings to use woody biomass, that we want the governor’s top aides to embrace as economic and environmental benefits from rural areas of the state.
Needle-exchange proponents say the programs reduce the spread of blood-borne diseases and help reduce some of the harm of IV drug abuse. A rise in Hepatitis C and HIV infections in rural areas shows it may be time to promote them far beyond the big-city limits.
Photo via The AtlanticNeedle exchange programs help contain communicable diseases like Hepatitis C
“I’m bothering no one but myself,” said 52-year-old eastern Kentuckian Joseph Cook.
At least that’s how he felt in his younger days.
Twenty-five years later, sitting on the wrong side of the safety glass at the Letcher County jail, he sees things differently. It’s his third trip to jail on drug charges.
“I feel responsible because when my son was 15, he found my OxyContin, which started my son’s addiction to opiates,” Cook said.
His son now suffers from liver failure caused by the Hepatitis C virus, which he contracted using a contaminated needle to inject drugs.
A needle exchange program could have helped his son avoid the life-threatening disease, Cook said.
Needle exchanges allow people to trade used syringes for sterile ones. The programs can help reduce the risk of disease like hepatitis and HIV and create a safer path to recovery, according to the World Health Organization.
Dirty needles are the likely cause of an increase in new cases of Hepatitis C and HIV in rural places like southern Indiana’s Scott County earlier this year. The Centers for Disease Control and Prevention has linked drug injection and prescription opioid abuse to Hepatitis C outbreaks in four eastern states, including Kentucky.
While needle exchanges could help slow the spread of disease, the programs can be controversial. Part of that may be due to how people perceive IV drug users – as pariahs, the lowest of the low.
Cook doesn’t fit the stereotype. He worked as a coal miner for 29 years, earning up to $85,000 annually. But most of that went to purchase drugs.
“I was living a double life,” Cook said. “I was raising a family and working all at the same time functioning as an addict.”