Oregon’s chronic disease epidemic is the state’s leading cause of death, and the problem is getting worse.
But a rural community in Maine (and a couple that met in a not-so-romantic way) may hold the answer.
“Sandy and I met over a patient’s colostomy,” said Burgess Record, who was a summer orderly when he met his future wife, a nursing student named Sandy, in 1961.
“I always say it had to have been love at first sight because otherwise that wouldn’t have been the opportune place to meet,” he added.
A few years after that chance encounter, the Records were married and Burgess had finished his medical training at Yale. In the early 1970s, they moved to Farmington, Maine, where other idealistic young physicians and nurses had migrated to launch an innovative rural health program.
Their work was part of a larger vision set out by President Lyndon Johnson's Great Society initiative. It made money available to rural medical providers, and helped launch Medicare and Medicaid. As part of that effort, Johnson's administration hoped to reduce economic and racial inequality in the America.
“This was a very novel approach, and it was not necessarily an ideal place to do it because it turns out that Franklin County is very conservative,” Burgess Record said. “I didn’t know that.”
Franklin County, Maine, has a lot of similarities to Oregon’s rural areas. It’s former timber country flush with forested hills and tumbling waterfalls. But jobs became increasingly scarce there as wood product factories and paper mills shut down due to automation and changing economies.
Like much of rural America, Franklin County has regularly struggled with isolation, a lack of public transportation, virtually no public health funding and widespread substance abuse.
It’s a reliably Republican area, and it’s safe to say people there viewed a group of Ivy League-educated, Johnson-era Democrats with a healthy dose of skepticism.
“There were meetings to try to have us kicked out of town because they claimed we were ‘a bunch of communists,’” Burgess said. “You know, socialized medicine. You’ve heard complaints about that.”
Crossing the cultural divide in rural Maine wasn’t easy at first, but Sandy Record grew up in the state and was committed to the cause she and her physician husband had set out to accomplish.
The Records helped create “virtual teams” where nurses were matched with physicians to go out into the community instead of waiting for people to go to hospitals or clinics for health care.
The nurses met with school officials, employers and residents where they worked and lived. They tried talking them into blood pressure screenings — a novel idea at the time.
People resisted initially, but the nurses were able to convince Franklin County residents that simple medical tests could help save their lives.
They met potential patients in their day-to-day lives and maintained an ongoing conversation about their health, even if people couldn’t make it to see a doctor on a regular basis.
It’s an approach to chronic disease management that focused on the power of face-to-face interactions to change a wider community. There’s nothing like it in Oregon.
“It became very popular,” Sandy said. “Taking our program out into community buildings such as churches and fire stations and having citizens coming in, we had waiting lines.”
“By the end of four years, we had screened half the adult population in the entire county,” Burgess said.
With every screening the nurses carried out, they helped collect data on patients for the doctors to review.
When a patient finally visited a clinic, a physician would have a much more complete picture of that person’s health, rather than a single data point of illness, with which to build a health plan.
Over several decades, the medical staff applied their blood pressure outreach model to high cholesterol, physical inactivity, smoking and diabetes prevention.
They even cobbled together a closed-circuit, interactive TV network to create a ‘70s-era Skype — all so patients at remote clinics could see and be seen by physician specialists at the central facility.
“It is one of the more fascinating programs,” said Dr. Lawrence Appel, faculty director at Johns Hopkins Bloomberg School of Public Health. “It had a good comparison group, and it had long-term follow-up. Those are things that I like.”
That data, the “long-term follow-up,” is what sets the Franklin County program apart. It’s also what saved it from being quashed by budget hawks.
Around 15 years into the program, Maine's health department considered cutting funding to the Franklin County program. As the Records tell the story, state officials had misconstrued their program as similar to a failing effort in Rhode Island.
But just before the guillotine blade fell, a researcher compiled county data on chronic disease deaths across Maine.
“Lo and behold, Franklin County had either the best or second best mortality rates from chronic health conditions like stroke and heart attack, and from death overall, for any county in the state,” Burgess said. “So that was the first time we had objective information from an outside observer that something funny, something different, had gone on in Franklin County.”
“When community residents learned about these results, patients, nurses and doctors became very proud of what we all had achieved together,” Sandy said.
The people of Franklin County had reason to be proud. They were demonstrably healthier than other people in Maine, despite being poorer than most.
They were also saving money.
One 2011 estimate printed in the Journal of the American Medical Association showed Franklin County's 30,000 residents were saving around $5.4 million each year on hospitalizations alone. That's $180 each year for every man, woman and child in the county.
Though results in the Franklin County model are clear, most states — including Oregon — have not been able to maintain similar efforts because they require a substantial initial investment and years of maintenance to achieve results.
Convincing politicians and taxpayers to invest in health programs that can take years, if not decades, to show their full results has always been the biggest obstacle, according to the Records.
“Efforts to promote chronic disease prevention often get bogged down because of — I’ll call them political considerations that trump evidence,” said Appel, the Johns Hopkins professor.
Oregon health officials believe the state has many components in its favor to replicate the success of the Franklin model. Oregon’s community care organizations, for example, stay in regular contact with Medicaid patients. Oregon also has a trove of patient data collected by the state’s Health Promotion and Chronic Disease Prevention Section.
And Oregon has had a number of programs designed to address chronic disease. Those have included doctors being able to write prescriptions for kids to attend for free parks programs or for adults to get discounted vegetables at farmers markets.
But what Oregon has not been able to do is put it all together in a unified approach over a long period of time to stop the growing health crisis.
A solution to the state’s $8 billion problem would require government agencies, health care providers and average Oregonians to make healthy living a priority — both financially and culturally — just as the people of Franklin County have done for the past 40-plus years.
“But it’s long term,” Sandy Record said. “It isn’t something you can just fix. It’s going to be chronically there. And how can you best manage it to keep patients out of the hospital and keep them living their life?
"That’s the challenge.”