Boston Globe, May 20, 2008: In Maine, a losing battle for health

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By Jenna Russell, Globe Staff | May 20, 2008

STEUBEN, Maine – Thelma MacLean doesn’t know what caused the chronic respiratory illness that has sucked away her mobility, peace of mind and resilience. Maybe it was the cigarettes she smoked for 30 years, or the woodsmoke she inhaled from neighbors’ stoves, or the home permanents she gladly gave her friends. Maybe it was all those things – “not just smoking, but your way of living,” as her doctor said.

The consequences, though, the 66-year-old knows well: The oxygen tube she depends on, always looped under her nose. The constant fear that she might catch a cold. The shortness of breath that keeps her inside her Route 1 home, where a miniature lighthouse decorates the lawn.

Like other women in Washington County, Maine, on the state’s poor, rural, eastern edge, MacLean has struggled to hang on to her health. It is a fight many women here are losing, according to disturbing new research published last month. Stunning findings in a national survey of life expectancy revealed a downward slide more often associated with developing nations: From 1983 to 1999, as most Americans were living longer, the projected lifespans of Washington County women grew shorter, along with those of women in 3 percent of all US counties, mostly in the South and West, according to researchers at the Harvard School of Public Health and the University of Washington.

To women who have spent their lives in remote eastern Maine, making ends meet by toiling in factories or raking blueberries or clamming, the study confirmed a harshness they already felt.

“It is another bit of unfairness, and there is so much unfairness,” said MacLean, the daughter of a Jonesport lobsterman, as she sat at her kitchen table one morning last week, watching hummingbirds hover at a feeder outside the window. “Washington County is a hard county.”

Sprawling down the rocky coast from Steuben, beyond Bar Harbor, to the Canadian border, and stretching north over miles of inland lakes and thick pine forests, Washington County is twice as big as Rhode Island. It is also rural and remote, uncrossed by major highways and sparsely populated. After years of economic stagnation and slow outmigration, fewer than 33,000 people remain.

For those who do, good-paying jobs are few. More than 11 percent of county residents are unemployed, twice as many as the state average. Work that can be found, like digging clams and worms, is often physically grueling, with low pay and no health insurance. Nineteen percent of residents live below the poverty line, more than in any other Maine county, according to the 2000 Census. Sixteen percent have no health insurance.

“It’s one of the richest counties and one of the poorest,” said Dr. Dora Anne Mills, Maine’s public health director. “It has rich traditions and culture, ocean and freshwater fishing, blueberries and a beautiful landscape, but it’s been plagued by poverty for decades, and poverty is one of the biggest factors in health and longevity.”

Overall across the country, life expectancy increased more than seven years for men and six years for women between 1960 and 2000. But when researchers combed through mortality data for individual counties, they found startling inequalities: Four percent of men and 19 percent of women live in counties where life expectancy has stayed the same or declined since the 1980s.

“No question, it’s a pretty shocking number,” said one of the researchers, Ari Friedman, a fellow at the Harvard Initiative for Global Health.

Three percent of all counties – 180 in 22 states – showed a statistically significant drop in life expectancy. The worst deterioration was seen across the South, in Appalachia and in parts of Oklahoma, Kansas, Colorado, Texas, and Wyoming.

In the Northeast, Washington County was the only place where life expectancy dropped, after making steady gains in the 1960s and 1970s. The decline was seen only for women. Between 1983 and 1999, the most recent data available, their projected lifespan fell from almost 79 to 77.6, a loss of more than a year, while nationwide, women gained about the same amount of time, achieving life expectancy of 79.6.

Men in Washington County added 2.3 years to their lives, on average, in the same period, though their projected lifespan was still several years shorter than that of women, a nationwide trend. Researchers say it is hard to pinpoint why women saw more decline than men, but one reason is smoking rates for women that took time to catch up to men, setting up later-peaking rates of lung disease. In Maine, specialists and residents suggested another, subtler factor. “Sometimes women are so busy taking care of others, they don’t take care of themselves,” said Mills.

The study found more women in the worst-hit counties died from lung cancer, chronic lung disease and diabetes, diseases linked to obesity and smoking. Those risk factors are alarmingly widespread in Washington County. In 2006, almost one-third of residents, 31 percent, were obese, compared with 23 percent statewide, and 29 percent smoked, compared with 21 percent in the state.

Twelve percent of residents have diabetes, and the death rate from the disease doubled from 2001 to 2006, to twice the state average, according to a study by the Center for Health Policy, Planning and Research at the University of New England in Portland.

“People don’t get good treatment for these conditions,” said Ronald Deprez, the center’s director. “There aren’t enough primary care physicians or adequate patient self-management. People don’t have transportation or money for medications.”

In a tiny red house beside Route 1 in Milbridge, Dolly Jordan matter-of-factly described a lifetime of poverty – swiping her former husband’s pocket change to buy food for her five children; making macaroni-and-ketchup suppers when tomato sauce cost too much. These days, the 61-year-old is obese, with high blood pressure and diabetes. Badly hurt when her car was hit by a drunk driver 16 years ago, she said, she is dependent on a wheelchair and in chronic pain.

Jordan sees her doctor less often than she should, because it’s hard for her to get out, she said, and she doesn’t exercise because she can barely stand. With $97 in monthly food stamps, she stocks up on hot dogs, hamburger, and chicken, hunting through the freezers for the cheapest packages.

County health professionals say the region’s problems are compounded by its lack of public transportation and the difficulty of recruiting doctors to an isolated place where winters are long and private insurance is rare. The Harrington Family Health Center, perched like a big white farmhouse next to Route 1, with 20,000 patient visits per year, has been searching for a dentist to hire for four years.

To encourage good habits, the health center built a walking track in an adjacent field two years ago. Staff members say they have been amazed and encouraged by its popularity, even in the dead of winter. On a sunny afternoon last week, the narrow oval teemed with walkers.

Elsewhere, though, people are stymied by hopelessness, said state Representative Anne Perry, a nurse practitioner in Calais, at the far eastern end of the county, and the chairman of the Legislature’s Health and Human Services Committee. The county’s economic aspirations have been shaken, she said, by the defeat of three casino proposals and the collapse of a planned ecotourism center.

“They’re trying and, time and time again, things haven’t worked,” she said. “The really disturbing thing is, if we don’t take a look at health care in this nation, the problem will get worse.”

To Thelma MacLean, living with lung troubles, the study is bad news, but the news is less than shocking. “We’ve lived this way for years,” she said. “We just don’t holler loud enough – or else they don’t listen.”

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