When Ephraim Trembly located his brother in a rural part of Maryland, John had already been deceased for three days. The circumstances surrounding John’s death were uncertain, as his body was in an advanced state of decomposition, making identification only possible through a tattoo. John Trembly Sr., their father, expressed that traces of fentanyl were found by the coroner, leading to the assumption that John had overdosed. However, the autopsy uncovered another unusual detail – at the young age of 20, John’s cardiovascular system had been severely compromised.
Before his passing the previous year, John spent the majority of his life in Terra Alta, a small town in West Virginia with a population of under 1,500 residents. Recent research indicates that a significant portion of Americans living in rural areas face health challenges, leading to a shorter life expectancy compared to those in urban settings. A concerning trend emerged between 2010 and 2022, with a notable 21% increase in cardiovascular-related deaths among working-age adults in rural regions, as reported in the Journal of the American College of Cardiology.
Dr. Rishi Wadhera, a cardiologist from Beth Israel Deaconess Medical Center and the senior author of the study, highlighted that this research provides the first comprehensive analysis of rural cardiovascular health during the Covid-19 pandemic. The data reveals a disturbing reversal of progress in reducing heart disease and stroke deaths, particularly in rural areas, where the disparity with urban regions has exacerbated over time.
Dr. Chris Longenecker, the director of the global cardiovascular health program at the University of Washington, noted that the study’s findings shed light on the longstanding challenges faced by rural communities in terms of cardiovascular health. Factors such as substance abuse, poor health habits, and limited healthcare access have contributed to the widening health gap between rural and urban populations.
The loss of John Trembly Jr. at such a young age due to cardiovascular complications underscores the urgency of addressing these disparities. The study urges a closer examination of the driving forces behind the rural-urban health divide and emphasizes the need for interventions to prevent further loss of life.
John Trembly Jr.’s father revealed that his son maintained a demanding schedule by working during the day and cleaning businesses at night. To cope with the workload, John resorted to using methamphetamine to stay awake and increase his productivity. When his girlfriend was hospitalized for a month, John took on her cleaning duties in addition to his own, all while traveling two and a half hours daily to visit her. Despite juggling the workload of two people, his boss remained unaware of his girlfriend’s hospitalization.
Unfortunately, the use of methamphetamine is linked to heart disease and stroke. John’s father suggested that his chronic usage likely damaged his cardiovascular system and may have played a role in his untimely death. These challenges are exacerbated by the limited access to healthcare in rural communities, making it difficult to attract primary care physicians and cardiologists. This lack of healthcare access hinders early intervention for conditions like cardiovascular disease.
The Covid-19 pandemic further intensified these issues, with a study revealing a higher increase in cardiovascular mortality in rural areas compared to urban areas. The pandemic acted as an external stressor, worsening existing social determinants. For instance, overdose deaths surged during the pandemic due to disruptions in treatment resources, leading people to turn to drugs as coping mechanisms. Preventive screenings and hospitalizations for heart attacks and strokes declined significantly, partly due to fears of seeking care in overwhelmed healthcare settings.
While telehealth was intended to address these gaps, evidence suggests it may have widened disparities, especially in rural communities lacking internet access. Patients in such areas faced challenges accessing care remotely, highlighting the urgency to bridge this digital divide. Implementing innovative solutions in rural America involves more than just medical advancements; it requires a holistic approach to deliver essential care to patients.
In response to these challenges, institutions like West Virginia University have taken steps to address healthcare disparities by hiring more healthcare professionals and acquiring struggling rural hospitals. Dr. Jeremiah Hayanga, a cardiothoracic surgeon at WVU, emphasized the importance of community-driven solutions to improve healthcare delivery in rural areas. Dr. Longenecker leads a research network aiming to adapt global healthcare delivery practices to benefit rural communities in the U.S.
John Trembly Jr., who used to clean rental houses and businesses, exemplifies the struggles faced by many in rural America.
When she fell ill, he resorted to methamphetamine to keep up with his responsibilities, using the drug to stay alert and work more efficiently. One of his projects involves training individuals who have undergone addiction treatment to conduct heart failure assessments within the meth-using community. Another initiative provides ultrasound equipment to community healthcare workers to screen patients for heart disease. Dr. Longenecker highlighted the success of similar approaches in Uganda in early detection and prevention efforts, prompting the question of why a similar strategy couldn’t be effective in Native American reservations.
The overarching goal is to transcend geographical obstacles by bringing cardiovascular care services closer to the people who need them. Drawing inspiration from successful models in African countries that offer HIV care in community settings, the United States is increasingly introducing blood pressure services in barbershops to cater to the needs of Black Americans. Dr. Longenecker questioned what the equivalent of a barbershop might be in rural America, emphasizing that managing hypertension doesn’t require complex medical facilities and can be effectively implemented in community spaces such as libraries or churches.
Central to this approach is active community involvement, as Dr. Longenecker stressed the importance of tailoring healthcare services to meet the unique needs of different rural populations. Acknowledging the diverse experiences of communities like the Cherokee Nation, residents of the Alaskan frontier, and Black Americans in the rural South, known as the stroke belt, he underscored the necessity of addressing disparities through targeted interventions.
While discussing the limitations of existing research, Dr. Longenecker emphasized the need for rigorous implementation science to reshape healthcare delivery mechanisms in rural areas. He raised critical questions about restructuring services to address disparities directly within these communities, emphasizing the importance of engaging with local residents to drive meaningful change.
Enhancing healthcare delivery is crucial in mitigating cardiovascular disparities in rural areas, but it’s equally important to address the underlying socioeconomic challenges. Dr. Hayanga pointed out the impact of the decline in coal mining on communities like West Virginia, highlighting the need for robust support systems to sustain livelihoods in the face of vanishing industries.
Despite the challenges, both Dr. Hayanga and Dr. Longenecker expressed optimism about the growing attention and funding directed towards understanding and rectifying rural-urban healthcare disparities. They noted the increased focus on this issue at the national level, particularly in the political sphere where the representation of rural states by the Republican Party could shape future policy decisions affecting rural health outcomes.
Reflecting on the personal toll of inadequate healthcare access, John Trembly Sr. lamented the helplessness felt in the face of systemic challenges. His poignant question – “What can we do? How can we help?” – epitomizes the profound impact of disparities on individuals and families grappling with limited resources and support.
As the conversation around rural healthcare intensifies, the urgency of addressing these disparities becomes increasingly apparent. The voices of community members, healthcare providers, and policymakers converge in a shared commitment to bridge the gaps and ensure equitable access to quality care for all individuals, regardless.
