Health Disparities In Appalachia

We appreciate the article by Gopal Singh and coauthors (Aug 2017), which documented widening health disparities in Appalachia. The authors mentioned that there are important regional differences within Appalachia but did not analyze them. In our view, these differences are critical to understanding where health problems are concentrated, and thus where improvement efforts should be directed.

We used mixed model regressions to analyze national total age-adjusted mortality rates from the Centers for Disease Control and Prevention for 1990–2013.¹ We found that Appalachia as a whole experienced a widening gap relative to the rest of the United States, consistent with the results of Singh and coauthors. However, we found that some of this gap was not related to Appalachia per se but to effects in the thirteen-state region that contains Appalachia.

Including this effect, mortality rates were higher in southern and central Appalachia but lower in northern Appalachia, compared to the rest of the United States. Most importantly, we also divided Appalachia into four regions, separating from the rest of central Appalachia the region where mountaintop-removal coal mining occurs. In that region and in southern Appalachia mortality rates were significantly higher than in the rest of the United States—and the difference was much greater in the mining region of central Appalachia. In comparison to the rest of the country, rates were lower in northern Appalachia and not different in nonmining central Appalachia. This model controlled for smoking status, poverty, rurality, obesity, percentage of the population that was African American, and physician supply.

To reduce disparities between Appalachia and the rest of the nation, it will be important to focus on southern Appalachia and, especially, the portion of central Appalachia characterized by continued dependence on coal mining.

NOTE

• 1 Centers for Disease Control and Prevention. Compressed mortality file [Internet]. Atlanta, GA: CDC; [last reviewed 2016 Dec 22; cited 2017 Sep 7]. Available from: https://wonder.cdc.gov/mortSQL.html Google Scholar