John had been dead for three days when Ephraim Trembley discovered his brother in rural Maryland.
His father, John Trembley Sr., said it remains unclear how John died because his body was so badly decomposed that the only way to identify him was through his tattoos. The coroner found traces of fentanyl, so it makes sense that John had overdosed, his father said. But the autopsy revealed something else, something even more unusual. At age 20, John’s cardiovascular system had been destroyed.
Until his death last year, John had lived most of his life in Terra Alta, a West Virginia town of fewer than 1,500 people.
One-fifth of Americans live in rural areas and have a life expectancy three years shorter than those in urban areas, primarily due to heart disease and stroke. And a study published last month in the Journal of the American College of Cardiology found that this disparity widened from 2010 to 2022, driven by a 21% increase in deaths from cardiovascular disease among rural working-age adults. That’s what it means.
Dr. Rishi Wadera, a cardiologist at Beth Israel Deaconess Medical Center in Boston and lead author of the study, said this is the first study of local cardiovascular health during the COVID-19 pandemic. He said it was a national analysis. Deaths from heart disease and stroke had been declining in both rural and urban areas until 2019, but spiked with the onset of the pandemic in 2020, reversing decades of progress.
“It is inexcusable that young people everywhere in this country are experiencing increased mortality from cardiovascular disease,” Wadera said.
Dr. Chris Lonecker, director of the Global Cardiovascular Health Program at the University of Washington in Seattle, said the results are not necessarily surprising because cardiovascular mortality rates are consistently worse in rural areas due to a collision of factors such as drug use. No, he said. have poor health and limited access to care; But the study renews questions about what is causing these widening disparities and what, if anything, can be done to stop the bleeding.
“No one wants to see their 20-year-old son die when he has everything in his life,” Trembley Sr. said. “That’s really unfair.”
Factors that create disparities between rural and urban areas
For Wadera’s study, he and his team examined age-specific death certificate data for more than 11 million adults. Between 2010 and 2022, deaths from cardiovascular disease increased among people aged 25 to 64 but decreased among people aged 65 and older. Rural communities experienced faster rates of increase and slower rates of decline compared to urban areas.
At one level, these disparities come down to differences in underlying risk factors. Longnecker said high blood pressure, diabetes and obesity have all increased in young people over the past decade, with rural areas particularly affected. This is tied to systemic issues such as declining health education, rising unemployment, and difficulty in easily accessing gyms and fresh food.
Small towns and rural areas have also been particularly hard hit by the opioid crisis, which not only worsens people’s economic situation but also directly contributes to deaths from heart disease, said Dr. George Sokos, chairman of the West Virginia University Department of Cardiology. It is said that there is Stimulant overdoses from methamphetamine and cocaine are also on the rise, increasing nearly ninefold between 2012 and 2022.
According to his father, John cleaned rental housing during the day and his office at night. To keep up with his grueling schedule, he began relying on methamphetamine to wake up and get to work faster. When his girlfriend was hospitalized for a month, John drove two-and-a-half hours every day to visit her while also taking on her cleaning duties.
“He was doing the workload of two people,” said Trembley, a senior. “His boss didn’t know she was in the hospital.”
But meth has also been linked to heart disease and stroke. John’s father said chronic use likely caused damage to his cardiovascular system, which may have contributed to his death.
All of these challenges are exacerbated by limited access to health care in rural areas.
“Our state is having a hard time attracting primary care physicians,” Sokos said, noting that this makes cardiovascular disease prevention and early intervention more difficult. And it goes without saying that there is a shortage of cardiologists to manage these conditions and treat complex cases. “We’re not seeing some of these young patients early enough,” he added.
The coronavirus pandemic has exacerbated these problems, with Wadera’s research showing that between 2019 and 2022, cardiovascular death rates rose by 3.6% in urban areas, but by 8.3% in rural areas. It turned out.
“The pandemic is an external stressor that has only exacerbated all of the underlying social determinants,” Lonecker said.
For example, overdose deaths skyrocketed during the pandemic as treatment resources were disrupted and people turned to drugs as a coping mechanism. With COVID-19 patients straining hospitals and closing rates in rural areas at record rates, preventive testing has plummeted and hospitalization rates for heart attacks and strokes have also fallen.
“It wasn’t just chaos due to stress in the hospital,” Wadera said. “Many people were simply afraid to come to a hospital or medical facility for treatment.”
Telemedicine was thought to fill this gap, but there is evidence that rural areas without internet access may be left behind and telemedicine may actually exacerbate disparities. In fact, more than one-third of West Virginia residents lack access, and fewer than half of those who do have high-speed internet.
“My patients drive to a gas station parking lot, go online, and do a telehealth visit from their phone,” Sokos said. “Patients want care. They just can’t get it.”
Future solutions
In rural America, reversing the rise in heart disease and stroke is not a matter of innovation.
“We have cutting-edge medical care here. We do robotic surgery that no one else in this country is doing,” Sokos said. “But just as important is getting out there and providing basic care to patients.”
Jeremiah Hayanga, M.D., a cardiothoracic surgeon at West Virginia University, said West Virginia University is helping to address these issues by hiring more physician assistants and nurses and sponsoring visas for foreign-trained doctors coming to the state. He says he is trying to work on the club.
Hayanga said that during the pandemic, the university also stepped in to buy struggling local hospitals to maintain access to health care across the region.
For Longenecker, moving forward requires a community-driven approach. To that end, he leads a research network that seeks to take lessons from health care delivery around the world and apply them to rural communities in the United States.
One project involves training people treated for addiction to go out into the community and perform heart failure tests on people who use stimulants.
Another company provides ultrasound machines to local health care workers so they can screen patients for heart disease.
“Uganda is using this approach to detect cases early and stop them from progressing,” Lonecker said. So, he continued, why doesn’t it work on Native American reservations as well?
Generally, the idea is to bridge geographic barriers and bring cardiovascular care closer to where people are, Lonecker said. In African countries, providing HIV care in the community has been highly effective, and in the United States, blood pressure monitoring services are increasingly being offered in barbershops for Black Americans.
“What is the equivalent of a barbershop in rural America?” asked Mr. Lonecker. “Treatment of high blood pressure is not rocket science. There is so much that can be done in the community, whether it’s in the library, church, or other places.
Central to this effort is active engagement with rural communities, he said. Ultimately, the experience of the Cherokee people would be very different from that of black Americans living on the Alaska frontier or in the rural South, sometimes referred to as the Stroke Zone. One important limitation of Wadera’s paper is that it does not examine racial or ethnic data or geographic differences between states. But this is where the work on the ground becomes necessary.
“Can you actually do rigorous implementation science in rural areas? How can you structure health service delivery differently in your region to address these disparities?” Lonecker he asked.
uncertain future
Improving health care delivery can certainly help address rural cardiovascular disparities, but it does not necessarily address the underlying socio-economic factors.
“This was an area that was once steeped in coal mining,” Hayanga said, noting that West Virginians are now suffering because those jobs have disappeared with few alternatives. He pointed out that “We need to help local communities earn a living.”
Still, both Hayanga and Ronnecker are hopeful that renewed interest and research funding into the rural-urban divide will bring more national attention to the issue.
“There are a lot of rural states in Congress that are represented by Republicans who are currently in power,” Lonecker said. “I’m interested to see how this impacts rural health policy-making.”
But for John Trembley Sr. and his late son, any change would be too late.
“What can we do? How can we help? All we can do is stand back and watch,” he said. “I wish there were more ways I could help the people I love.”
