Frank Adams begins each day with a bowl of cereal. He used to eat a larger breakfast, complete with a serving of bacon or sausage — which he now calls “dead animals” — but he changed his ways years ago when his wife’s morning sickness kept her from cooking for him.
Now 74, Adams has continued to eat light and stay out of the doctor’s office. As founder of Keep Chatsworth-Murray Beautiful, his job allows him walks around the mountainous county he calls home. On those walks, he has seen that his lifestyle is anything but normal for Murray County.
As it turns out, Adams’s observations may help explain why the health of his Murray County neighbors is markedly different from that of neighboring Pickens County residents.
Several organizations have studied health status in Georgia’s counties and produced rankings based on a variety of factors. In 2010, the public health advocacy program Partner Up for Public Health ranked all 159 Georgia counties. Murray County ranked 95th; Pickens County, its neighbor to the southeast, was ninth.
Recently, the University of Wisconsin published its 2012 rankings of nearly every county in the nation, including 156 of Georgia’s 159 counties. In their health rankings, Murray ranked 106th to Pickens’ 27th.
The contrast is striking because the two counties are similar in many ways. Located in North Georgia, both counties are largely rural, with predominantly white populations. But for a variety of reasons, Pickens County is a relatively healthy county while Murray County is not.
A simple question, a complicated answer
Murray and Pickens comprise one of five pairs of neighboring counties with markedly different health profiles, based on both Partner Up and University of Wisconsin data. The other pairs are Pike and Upson, Glynn and Wayne, Lee and Terrell, and Houston and Twiggs.
With the other four pairs, however, the reasons for the differences in health status are more obvious. Age, gender, race and socioeconomic status are the primary factors leading to these kinds of health disparities, according to Christopher Whalen, professor of epidemiology in University of Georgia’s College of Public Health. In each of the other pairs of counties, big enough differences in demographics would explain the health disparities.
For Pickens and Murray, it’s not as clear cut.
‘It still doesn’t fit all together’
One major difference between the two counties is wealth. Murray’s per capita income is $24,000 and its median income is $39,000, while Pickens per capita income is $34,000 and its median income is $51,000. Murray also has a higher percentage of uninsured, 24 percent of residents vs. 20 percent.
Yet other major factors influencing health don’t add up. Both counties are about 90 percent white, and the people of healthier Pickens County — which ranked better on cardiovascular disease deaths, cancer deaths, and diabetes — are older than those of Murray County.
“It still doesn’t fit all together,” said Whalen. “For example, you’d expect a county with an older age distribution to have a higher rate of age-adjusted cardiovascular disease death. But it actually turns out to be significantly lower.”
Whalen said he doesn’t think the income gap is wide enough to explain the disparity.
Pickens’ high ranking puzzles some of its residents as well.
“I’m surprised,” said Heather Day, who lives in Pickens County but works as a 911 dispatcher in Cumming. “We’re all rednecks; everything has to be fried.”
On Partner Up for Public Health’s county-by-county map, Murray County sticks out like a sore thumb. As the people of Murray are so similar to their neighbors — save for their health— the counties deserve a closer look.
Paradoxically, the same factor making some counties sicker could be keeping Pickens County healthy. With 16.3 percent of its population over 65, Pickens County is home to two major retirement communities, Bent Tree and Big Canoe.
“Maybe the level of education in those communities is a lot higher, and maybe the patient awareness is going to be better and they are more attuned to taking care of their health,” said Moiz Master, a Pickens County primary care doctor.
Having practiced in Pickens County since 2003, Master has observed how residents are receptive to information on health, complying with recommendations for preventive care and attending frequent health fairs.
Availability of primary care
Murray County has far fewer primary care providers than Pickens.
In Pickens, there are about 1,400 residents for each of the 22 primary care physicians, according to the Wisconsin study; in Murray, there are nearly 5,800 residents for each of the seven primary care doctors. While both counties have a larger number of residents per physician than the Georgia average of 1,024, the severity of Murray’s physician shortage could explain the deluge of patients who make the emergency room their first medical stop.
“You will see that if you look at the emergency room statistics at the local hospital — so many unassigned patients, patients who are not established with a provider,” said Naomi Fehrle, a nurse practitioner in Sutter Family Practice Clinic in Murray County.
Since the economic downturn, Fehrle has seen many patients drop their insurance and subsequently their primary care.
Fehrle’s observations are echoed by Mike Robertson, president and CEO at Piedmont Mountainside Hospital, in Pickens County: “Physician recruitment is key for the success of any hospital. So if you cannot recruit and retain talented and qualified physicians, in small-town communities those patients will leave the market for their health care or go without.”
The higher levels of income and insurance, though, could explain, at least in part, the greater number of physicians in Pickens.
The high number of Murray County residents who lack a primary physician may be due to its larger Hispanic population. While only 2.8 percent of Pickens County identifies as Hispanic, Murray County is 13 percent Hispanic.
“The tendency [among Hispanics] is not to seek health care until they really, really need it,” said Jennifer King, public information officer for the North Georgia Health District.
People of all ethnicities have fallen upon tough times in Murray County as some of its major employers have shut down. Unemployment in Murray County generally runs about 2 points higher than in Pickens.
In 2011, Shaw Industries shut down its spinning mill in Murray. According to city-data.com, textile mills account for 35 percent of Murray County’s jobs, whereas the people of Pickens work primarily in construction.
The nature of the industries themselves could have some bearing on disparities in health. While treating carpet mill workers, Fehrle has noticed that they suffer from joint pain, which could keep them from exercising regularly.
Food: The good, the bad, the clumped together
Of course, a major factor contributing to Murray County’s high levels of obesity, diabetes and heart disease is what its citizens eat. Perhaps it isn’t the number of fast-food joints and grocery stores available that counts; perhaps it’s their location (see slideshow).
While Jasper in Pickens County boasts two parks and four grocery stores in its town center, 3rd Avenue runs through the middle of Chatsworth in Murray County like cholesterol through an artery. Two blocks of 3rd Avenue feature eight fast food restaurants and, ironically, one of the only sidewalks in town.
“Those restaurants are there for a reason: Because they’re used. The restaurants have done their research and know that if they put a restaurant there, it’s going to be used, whereas if they put a restaurant in the other location, people are less likely to use it,” said Whalen.
Altogether, Murray County has 26 fast food restaurants versus Pickens’ 15, according to University of Wisconsin data. Not surprisingly, the UW study also found that a higher share of Murray County residents have limited access to healthy food than their counterparts in Pickens – 29 versus 21 percent.
The better access to parks, gyms and grocery stores in Pickens could be linked to its higher incomes, though other factors, such as business and civic leadership, may have a role as well.
Echoing Frank Adams’s observations, more people are physically inactive in Murray than in Pickens (32 percent versus 24 percent), and there’s a similar contrast in adult obesity: 30 percent in Murray to 26 percent in Pickens.
If fast food providers can conduct research to maximize business, public health researchers can conduct research to maximize health.
The data compiled by Partner Up for Public Health and the University of Wisconsin comprise an ecological study — focusing on populations as a whole. To definitively answer questions about health disparities, each of the possible culprits calls for a closer investigation.
“To really answer the question, these kind of case-control studies, these kinds of individual level studies are the only way to do it,” said Wagner. “That’s the only way to say X causes Y.”
It’s not only sickness that merits investigation, but also health.
“Pickens, despite its proximity to Atlanta, is still pretty rural. If it’s ranked ninth in Georgia then that means the people of Pickens are doing something right. And it’s important to know because if you can identify the differences between Pickens County as compared to Murray, then you may be able to help counties like Murray out,” said Master.
“Small things like that can impact a community in a big way in the long run.”
Chelsea Toledo completed her master’s degree in Health and Medical Journalism from the University of Georgia in May 2012. This summer, she will intern as a science writer at the National Institute of General Medical Sciences, a branch of the National Institutes of Health in Bethesda, Md.