This figure is from the U.S. Health Map, created by the Institute for Health Metrics and Evaluation. It shows how gains and losses in life expectancy are quite unequal across the United States.
Take a look at the map at the top of the page. It shows differences in life expectancy over time across all counties in the United States. As someone from Appalachian Kentucky, my eyes instantly lock in on a cluster of counties – Leslie, Lee, and Owlsey – that are clearly the darkest of red. As it turns out, there are only 7 counties in the entire United States where life expectancy has actually decreased over the past 40 years, and all of these are in Eastern Kentucky. There are only 3 counties where life expectancy has decreased by more than a year over that stretch of time, and those are the dark crimson counties on the map. We are going to be talking about Leslie County today, and keep in mind that if you were born in 1980 in Leslie County, you could expect to live a longer life than a child born today. And at the same time if you were born in 1980 in Leslie County, you could still expect to die about 10 years younger than the average American, almost entirely because of poor health.
Imagine being a hospital and healthcare facility that has a mission to prepare competent, entrepreneurial, ethical, and compassionate leaders in primary care to serve all individuals with an emphasis on women and families in diverse, rural, and underserved populations. Where would you be better situated to fulfill that mission than in Leslie County, Kentucky? Indeed, there are a number of factors that make Leslie County the center of health inequalities in the United States – life expectancy is one vivid example – but poor nutrition, chronic disease, and infant mortality are others. So, why has Frontier Nursing University, which was founded in Leslie County and has a mission to serve “women and families in diverse, rural, and underserved populations” abandoned this place? Far worse, it has now stolen local historical artifacts without warning to decorate its new campus in suburban Versailles, KY, one of the wealthiest communities in the Commonwealth.
We should be enraged that a non-profit corporation would take advantage of a community already as marginalized and oppressed as Leslie County. The sad part is, they may well do it again. We need to demand action from the Board and CEO to ensure that such decisions are not made again and that they renew their commitment to the community that gave them such strong roots.
The History of Frontier Nursing
If you have been to Hyden, population 338 and the only town in Leslie County, you know it is in an absolutely beautiful and rugged location. Mountains loom high and the only roads follow along narrow creeks. In the early 1900s, the folks who lived along those mountainsides had almost no access to healthcare. In particular, many babies and mothers died at childbirth or soon after, with nobody to attend to the births. And so an enterprising group of women nurses set out, on horseback, to tend to the mountain people. They were known as the frontier nurses.
Mary Breckinridge at work
Among these nurses on horseback was a true heroine, Mary Breckinridge. She was widowed at 26 and then lost her two young children. Instead of drowning in her grief, she devoted her life to serving the people of rural Appalachia, and Hyden in particular. She established the Frontier Nursing Service in 1925, creating an entirely new model of serving rural and isolated families by having a system of nurses who visited them at their home. Then, in 1939, she established The Frontier Nursing School of Midwifery and Family Nursing in Hyden. The work she started took strong root, eventually becoming Frontier Nursing University (FNU). This is the longest continually operating nurse-midwifery program in the country, established out of a desperate need in one of the most rural and underserved places in our country.
So imagine the absolute shock when, in 2017, FNU decided to move all of its operations to a wealthy bedroom town just outside of Lexington, ironically named “Versailles.” To be clear, it made this decision at a time when infant mortality in the Kentucky Mountains is still 21 percent higher than the national average (read more from the Appalachian Regional Commission here: https://www.arc.gov/assets/research_reports/Health_Disparities_in_Appalachia_Child_Health_Domain.pdf), and when 40% of children in Leslie County still live in poverty. It did not decide that Hyden or the surrounding people of Leslie County no longer needed their operations in their community; instead, it sought convenience and expansion. And rather than come up with innovative model that would allow folks to be employed still in Leslie County and move rotations through, they simply decided to leave.
A Harsh Reality of Maternal Care in Appalachia
It is hard to describe how deeply this is corporatization of education, healthcare, and mission. You can take a look at this table that summarizes the statistics comparing Leslie County and Woodford County, home of Versailles. As you can see, Leslie County has a high concentration of teen mothers, mothers without high school degrees, and low birth weight babies. We could go further down that list, talking about clean drinking water, or access to sports or fitness activities. The end result of those challenges are spelled out in the numbers.
This information is from the Kentucky KIDS County Database: https://kyyouth.org/kentucky-kids-count/#countyprofiles
Still, the hard thing about statistics is that they don’t convey the real story behind the number—the absolute heart wrenching struggle of how difficult it is to survive when you live in rural, underserved parts of Appalachia. But, I am going to try by sharing a personal story. This is a trigger warning for pregnancy loss. You can pick the story back up at the heading “Plundering History” if you want to skip this section.
I was living in rural Harlan County, very near the Leslie County line on the morning I realized that I was losing a pregnancy at 16 weeks. It was August 3, 2016. My husband was at work and my two young children were with me when I began to hemorrhage. Those who have been through it know it is a terrifying experience, but what made it extra difficult was a struggle that nobody should have to face: I had no good options for hospital care nearby. I called around to local women, and we had an urgent exchange about where I might go. There was a mountain between me and any hospital, and it would take at least 30 minutes of driving over rugged terrain to get to any of them. But even worse, many of them had a terrible reputation for emergency care. We talked about which might be the best choice. I called my husband; we set out bracing ourselves for a bad experience.
We ended up at the Pineville Community Hospital after a 45-minute drive. When I was finally ushered into an ER bay after a long wait at the reception desk, I was left on a bed with a thin curtain separating me from a man having an asthma attack. There were no fetal monitors, no attempts made to try and gauge the situation or see if something could be done. They did not even have equipment that would allow them to listen for a heartbeat. When the doctor finally strolled in, he made a crass comment that he was sure that we regretted coming there, informing us that their equipment was from the 1950s. It certainly seemed that way—the ER looked like a set from the Mad Men era, only badly worn over time.
Eventually, I was taken into a room for an ultrasound, but the machine was outdated and there were no clear results. As before, I was left alone for long stretches, and I agonized about what we should have done. Should we have driven the 2 hours to get to a bigger hospital? Or the 3 hours it would have taken to get to Lexington? Ultimately, I delivered the baby alone in the ER bathroom. When I informed the ultrasound tech, she rolled her eyes and said she guessed she would have to clean it up. She then disposed of the baby before there were any options to test and see what might have gone wrong, but not before depositing the tiny baby in a jar and waving him in my face. Although I was still bleeding heavily, my husband and I decided that we had to leave the hospital, refusing any further care and signing a waiver. To be honest, I was worried that if I stayed I would end up with an infection that could kill me. I thought I was more likely to live if I simply went home.
We later got a bill from the hospital and doctor separately, for over $7,000 combined. It was not covered by my insurance, which we had purchased on the healthcare marketplace.
It is a brutal story, but I share it because this is the brutal reality that women face everyday in rural Appalachia. In fact, the hospital I visited was so poorly managed that two years later Medicare refused to reimburse services because care was disgraceful. For example, ambulance drivers were routinely directly away after realizing that the hospital did not stock IV fluid or defibrillation equipment. You can read more about it in the article, “Citing patient safety violations, Medicare terminates contract with Kentucky hospital.” https://www.kentucky.com/article230944973.html. It was an experience so incredibly discrepant from the maternity care I received when I lived outside the region that I still have trouble wrapping my head around the fact that two such extremes exist in one country.
I don’t think I would believe it if I hadn’t lived it. And what absolutely guts me about it is that I am an educated person, very capable and practiced in asserting my needs. What would the experience be like for so many other women in the community, who are far more vulnerable than I am? Who are young, poor, and afraid?
I know the odds of a different outcome were low in my case. But I do still wonder what would have happened if I had good care in closer proximity. Would they have been able to stop labor? Would I have a living child today? We know far too many people who have to agonize over questions like these in our broader Appalachian region.
Of course, there are bright lights of health in rural Appalachia. There are nurses and doctors who do incredible work, often in difficult conditions and always with less pay than they would get in a different location. These people are heroes, and we rely on their dedication. We need every single one of them we can get in our community. If Mary Breckinridge were alive today, she would still choose—and be needed—right where she began in Hyden.
Plundering History
An image of the stained glass window gifted to Mary Breckinridge that was taken from Hyden
So now that we are clear that Frontier Nursing removed themselves from one of the counties in America with the very poorest health outcomes in the nation, we now come to one of the saddest parts of this story. It wasn’t enough to move out the paying jobs and important roles from the community. Instead, FNU has now taken historical artifacts from the community. From the outset, folks in Hyden were worried about log cabins and a chapel window that have historical status. These are items that were hand-built by local community members where they are deeply meaningful. They are the absolute heart of Hyden, but they make fun accessories at a campus in Versailles.
It is almost impossible to overstate the role that Mary Breckinridge plays in the community of Hyden. There is a festival named after her, and it is even the name of the local hospital. She lived there until her death in 1965.
Imagine, without notice, a priceless stained glass window just disappearing in the night. Under the cover of darkness, FNU removed the window from a chapel in Hyden that had been hand-buillt by local people. Without any notice, the piece was relocated to Versailles. The stained glass window was a cherished momento of Mary Breckinridge, given to her by a cousin in 1938. It was put in place in 1960 with the construction of the chapel and given, not to the University, but to the local people. It had served as a symbol of her faith, dedication, and the important role that the frontier nurses played in the community. She read the story of St. Christopher, who is depicted in the glass, every year at Christmas. She always said that since St. Christopher was the patron saint of travelers, he was the patron saint of the frontier nurses.
And now this important piece of history is gone. It is as if the very setting that inspired the work no longer matters. The people of Appalachia and their history can just be written off when they no longer have utility. What is the difference between this and removing mountaintops for coal? The people of Appalachia continue to be a commodity that others feel free to use.
We have taken their official statement and made it an image that you can click to read.
Here is the official statement released by FNU
Do What is Right: A Call to Action
Right now, we should have several concerns about FNU. Will they ever return the stain glassed window? Will they continue to take more historical artifacts from Hyden? How will they communicate to the people of Hyden and Leslie County? Will they return to their mission?
Because FNU is a non-profit, they are governed by a Board of Directors that makes decisions about the future and direction of the organization. You and I can contact the Chair and Vice-Chair of the Board and make these demands:
Commit to returning the original stained glass to Hyden, making a replica for the Versailles campus
Make a public commitment to keeping all historical artifacts of Mary Breckinridge in her home of Hyden
Ensure that the Board of Directors includes at least three members who are lifelong residents of Hyden
Below is the contact information of the Board Members. I hope you might take a moment to ask them to take these actions. But even more, we can make it clear that while the people of Appalachia may be small in number and political power, we are part of a community that is made mighty by our deep connections and resilience. I believe deeply in redemption, and I hope and pray for a good ending to this story.
The "Mary Breckenridge Chair" Michael Carter (term renewed April 2, 2020) mcarter@uthsc.edu
Vice Chair Michael T. Rust michael.rust@netscape.net
A frontier nurse at work
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