Medical Service for Rural Areas: The Tennessee Medical Foundation [Reprint 2014 ed.] 9780674600034, 9780674599338

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M E D I C A L SERVICES FOR RURAL A R E A S

MEDICAL

SERVICES

F O R R U R A L AREAS THE T E N N E S S E E M E D I C A L

FOUNDATION

BY WILLMAN A. MASSIE Chairman, Formerly

Health Field

Committee,

Secretary,

Council

of the Southern

The Tennessee

Medical

Mountains

Foundation

Published for The Commonwealth Fund by Harvard University Press Cambridge, Massachusetts 19 5 7

©COPYRIGHT BY THE C O M M O N W E A L T H

1957 FUND

LIBRARY O F C O N G R E S S C A T A L O G C A R D N O . 57-9541 M A N U F A C T U R E D I N THE U N I T E D STATES O F A M E R I C A

Published for The Commonwealth Fund By Harvard University Press Cambridge, Massachusetts For approximately a quarter of a century THE C O M M O N W E A L T H F U N D , through its Division

of

Publications,

sponsored,

edited, produced, a n d distributed books a n d pamphlets germane to its purposes a n d operations as a philanthropic foundation. O n July 1, 1951, the Fund entered into a n arrangement by which H A R V A R D U N I V E R S I T Y PRESS became the publisher of Commonwealth Fund books, assuming responsibility

for

their

production

and

distribution. The Fund continues to sponsor a n d edit its b o o k s , a n d

cooperates

with the Press in all phases of manufacture a n d distribution.

Distributed in Great Britain by Oxford University Press, London

CONTENTS

Preface, by Ralph Η. M o n g e r , M.D., President, The Tennessee Medical Foundation Introductory Note, by Harry E. Handley, M.D., Public Health Associate, The Commonwealth Fund

THE N E E D THE M E A N S

1 11

THE A P P R O A C H OTHER PROJECTS SUMMARY

47

Appendix A

51

Appendix Β

54

Appendix C

57

Appendix D

61

Appendix Ε

65

Appendix F

67

17 35

LIST OF ILLUSTRATIONS

C O V E R : Clear Fork V a l l e y s h o w i n g "strip m i n i n g . " I N S I D E C O V E R S : M a p of the Clear Fork IPruden) V a l l e y area. Clear Fork V a l l e y s h o w i n g "strip m i n i n g . "

2

E a g a n , a characteristic Prüden V a l l e y community.

6

A one-teacher school on Tackett Creek. The building w a s formerly used a s a bathhouse for miners w h e n mines were operating. 6 A typical " w o r k e d o u t " m i n i n g camp at A n t h r a s . Families m o v e d into these houses w h e n the camp w a s a b a n d o n e d b y the coal c o m p a n y — a n d p a y no rent. 7 Church a n d schoolhouse at V a l l e y Creek.

7

M i n i n g operation near the Kentucky-Tennessee b o u n d a r y line. School a n d p l a y g r o u n d at E a g a n . Clear Fork Community Clinic.

28

Clear Fork Community Clinic.

28

23

23

Clear Fork Community Clinic: office a n d h a l l w a y a s seen from reception room. Clear Fork Community Clinic: recovery room a n d nursery. Morgan

County Medical Center, W a r t b u r g .

La Follette Community Hospital.

34

34

Palmer Clinic: exterior a n d interior v i e w s .

40

29

29

PREFACE

The principal problem confronting the citizens of many communities is how and where to seek and obtain sound technical advice and guidance on social organization and professional needs. Clear and constructive thinking serves to eliminate waste and duplication of facilities and to achieve the most service for the economic resources available. Nearly all communities can improve the character of their health service by harnessing and directing local resources to support and maintain better standards for medical care. It is the conclusion of the Tennessee State Medical Association that there is no source or agency available to local people that is able or better prepared to determine the needs and assist in the establishment of an effective professional service than the State Medical Association. If this responsibility is not assumed by organized medicine, then who can or will offer this kind of help and guidance to the people? President The Tennessee Medical Foundation RALPH H . MONGER, M . D . ,

INTRODUCTORY

MOTE

This is the story of a program to improve the health service for a group of communities in rural Tennessee. No two communities are exactly alike, and some are markedly different from others, in their resources, community interests, and organization. It has been repeatedly shown that the quality of health enjoyed by the people is influenced by many factors which can be detected and measured. When accurately interpreted, the results of the investigation can be utilized to modify the organization of the community in a direction favorable to the health of its inhabitants. Recognition of need is one of the first steps toward community improvement. Definition of the need in understandable terms is another step. This is followed by review of the resources which can be utilized and development of a plan to accomplish the change desired. Next comes implementation of the plan and, finally, evaluation of results and planning for the future. The health needs of Pruden Valley attracted the attention of anyone who was willing to see or listen. The inhabitants themselves were reasonably well adjusted to their environment and while they certainly did not enjoy some phases of their existence, they were nevertheless experienced in the economic ups and downs which accompany the exploitation of a natural resource at the marginal level. In good times they shared their bounty with the promoters who swarmed into their Valley. They bought cars, washing machines, refrigerators, radios, and other gadgets of modern living. They even had ix

INTRODUCTORY

NOTE

reasonably good medical service because doctors also enjoy the fruits of exploitation, and occasionally a well-qualified physician came into the Valley. In slack times the promoters moved on, and, too, many of the able-bodied young men and women moved to other mining areas or to industrial centers; but always a substantial number of people, particularly the old folk, middle-aged women, and the children, remained behind to fare as best they might. There are many communities all up and down the United States which are in some respects like Pruden Valley. The question is, can such communities stabilize their health services at a higher level than that to which they have been accustomed in the past? A group of physicians in Tennessee experienced an unpleasant twinge of conscience when presented with the picture of Pruden Valley. They decided to do something about it and other communities like it. This is the story of their effort. HARRY E . HANDLEY,

M.D.,

Public Health Associate, The Commonwealth Fund

X

THE

NEED

In the mountainous area of northeastern Tennessee, not far from famous Norris Dam, lies a secluded valley with an area of about 100 square miles and a population of some 6,000 persons, mostly coal miners and their families. That is, they are coal miners when economic conditions permit. In good times as many as two-thirds of the adult males have worked in the mines, but in slack times, including every summer, as few as 10 per cent work. In recent years bad times have tended to predominate. Geologists of the Tennessee Department of Conservation have made detailed studies of the coal resources of the area and report that no more accessible virgin coal fields are left. Large-scale coal mining operations, therefore, are out of the question for the future. However, some miners can find employment in "truck mining" operations in small pockets of coal here and there which can be reached and mined economically. Non-miners find some employment at lumbering, farming, and small trades. Such activities are not conducted efficiently, however. Even to the casual observer, the waste of natural resources is apparent. The forests have not been adequately protected from fire, grazing, and poor cutting practices. Most of the land is owned by the American Land Company, a British concern which maintains a rental office in Middlesboro, Kentucky. Coal operators lease sections to be mined from this company, but, because of the temporary nature of their operations and lack of any incentive for future development, the leaseholders build their facilities as cheaply as possible and ι

PRÜDEN

VALLEY

abandon those which have little salvage value when the lease period is terminated or when continued operation becomes unprofitable. The American Land Company has depended upon fire, tower observation and local fire fighters to protect the forests, but these measures have not been adequate, and large areas have been burned over. Miners have cut the best young timber for mine props, and cattle have been turned loose to graze in the woods. Strip mining (surface mining of exposed veins) has cut ugly gorges from 25 to 30 feet deep extending sometimes for miles along the mountain sides.* These gashes have contributed to soil erosion. Gravel, washing down from the mountains, has in many places covered bottom lands which otherwise might have been suitable for small-scale farming, and has filled up stream beds and aggravated flood conditions. What little land is cultivated is usually planted to corn; there are only a few gardens and truck patches, and little or no poultry is raised. Several years ago, when attention was directed to the health problems of the area, sanitation was practically unknown. Streams and land depressions were filled with refuse; outdoor toilets were poorly constructed and unsanitary; trash and debris cluttered the sides of roads and the corners of buildings. In nearly all the settlements there were odors of decaying organic matter and overflowing septic pits. The water supply was poor. Much of the home supply came from wells and was full of iron rust; some came from springs and from creeks. None was chlorinated. Water pipes, when present, crossed each other indiscriminately, making it virtually impossible to distinguish the lines that carried water pure enough for drinking from those that carried water suitable only for washing and for watering stock. Organized health service was practically unknown in the * See illustration on the cover of this booklet.

3

THE NEED Valley. The county nurse came to the area infrequently and the sanitation officer visited the schools once every year or two, but merely reported his findings to the superintendent of schools. The postmistress at Clairfield attempted to gather and send to the health department vital statistics from her vicinity, but found it difficult to secure the necessary information as the "doctor" and the midwives were casual about reporting births. It is not surprising that county health and sanitary services were available only in attenuated form. Most of the Pruden Valley area lies in the northwestern part of Claiborne County, but the area also includes portions of Campbell County, Tennessee, and the southwest side of Bell County, Kentucky. As the crow flies, Tazewell, the county seat of Claiborne County, is little more than 20 miles from the center of Pruden Valley, but to reach the town by automobile, residents must drive 36 miles, crossing two mountains and passing through corners of Kentucky and Virginia. As a result of this remoteness, Pruden Valley is more an appendage than an integral part of Claiborne County. Public officials rarely visit the area and few residents of the Valley go to Tazewell unless they have to attend the county or circuit courts. The meager medical services that were available in 1953 were provided for the most part by inadequately trained, unlicensed "doctors." There was one "practitioner" from Middlesboro who went to Fonde and Pruden mining camps each morning and to Frakes in the afternoon. The "doctor" in Marion and the one in Eagan were not licensed. An elderly doctor who was licensed treated patients in the Morley area on top of the mountain. In earlier times, particularly when the area had been more prosperous, there had been some highly capable physicians, but as the monetary rewards diminished over the years the quality of medical service deteriorated. The nearest hospitals, in Middlesboro, Kentucky; and Jellico, Ten4

PRÜDEN

VALLEY

nessee, each 18 miles from the center of the Valley, were proprietary and had closed staffs. There were no dentists in the area. A lack of social and cultural opportunities was evident. There were no civic or community organizations in the area and no 4-H Clubs for the young people, although 1,200 to 1,500 were enrolled in such clubs in other parts of the county. The one women's club, organized under the auspices of the Home Demonstration Agent, had only a dozen members — all wives of men at the operator or management levels. There were two parent-teacher associations but the limited membership was composed of women of the upper levels of the community. There were no Boy or Girl Scout groups and no parks or playgrounds, although the area lent itself well to these activities and facilities. Library and general recreational facilities were virtually nonexistent. There were 22 churches in the Valley and an even larger number of preachers. One young minister who served as a missionary worker for all of the Baptist churches seemed to be a good leader. With the exception of Eagan, the Valley communities had relatively good school buildings, but only one seemed completely adequate. The educational system in the area included ten grammar schools and one high school. Only about half of the 36 teachers were fully qualified; the rest were teaching on permits. Pruden Valley has one great asset, however — its people. They are intelligent and self-respecting. The children who attend the schools of Pruden Valley may be poorly dressed, but they and their clothes are clean. In 1953 work at the mines was slack and the morale of the people was at a low ebb, but despite the fact that from half to two-thirds of the men were out of work, only 91 families in the entire area were receiving public assistance. There was no evidence of excessive drinking or lawlessness. For a more detailed picture of the Valley, it might be 5

A one-teacher school on Tackett Creek. The b u i l d i n g w a s formerly used a s a b a t h house for miners w h e n mines were operating.

A typical " w o r k e d o u t " mining cqmp at A n t h r a s . Families m o v e d into these houses w h e n the camp w a s a b a n d o n e d b y the coal c o m p a n y —

Church a n d schoolhouse at V a l l e y Creek.

a n d p a y no rent.

THE

NEED

interesting to make a tour from the upper part, in Bell County, Kentucky, down through the Claiborne County portion into Campbell County, Tennessee, visiting each of the larger communities as it appeared in 1953: At Fonde, the Clear Fork Coal Company maintained a commissary and camp. The mines were operating about three days a week, employing 60 to 70 men. There were approximately 300 families in the vicinity. At Pruden, where there were some 250 families, about 100 men were working at the mines from three to five days a week. At Valley Creek about 50 families still lived in the camp although the mines had been closed nearly ten years. In February of 1953 the commissary was closed and the camp was being abandoned. At Hamblen Town (in an area not controlled by the American Land Company) there were no mines, but a small village had sprung up along the highway with three or four stores, filling stations, and a cafe constituting the business district. The privately owned town of Clairfield served as a trading and school center for families along the highway and up Rock Creek toward Marion. Clairfield, once a bustling village, was gradually dying out. At Marion, further up Rock Creek, the Black Diamond Coal Company had closed down and leased its property to the Arnold Coal Company which was engaged in small strip mining operations. The Dippel Coal Company also carried on strip mining operations in this area, employing about 30 men, including truck drivers. Along the road to Buffalo up a side valley the housing consisted mainly of small, poorly constructed shacks, most of them occupied by large families whose children were ragged and unkempt in appearance. There were some 30 to 50 families living along this road and in little pockets that extended back into mountain gulches. The little two-room school build8

PRÜDEN

VALLEY

ing set on the edge of the road had a very limited playground area. A small church perched on the side of a hill nearby. At Eagan, the largest community in the area, and the last in Claiborne County as one goes down the Valley, the Blue Diamond Coal Company was carrying on fairly heavy operations. There were approximately 400 families in the vicinity with 200 men working in the mines. Eagan had a movie which ran two or three nights a week and a pool-room which was temporarily closed. Even the baseball and softball teams were not organized in the summer of 1953. The medical "practitioner" in the area had no formal medical school training but seemed to be in good repute with the people. The next four to five miles, in the Campbell County part of the Valley, were sparsely settled, with perhaps half the families living in old houses in abandoned coal camps. There were no mining operations in this section except a few "wagon mines." The New Jellico Coal Company operated on top of the mountain, essentially out of the Valley area. There were 100 families in the immediate vicinity of the mines, but employees were drawn from a much wider area, some from as far as Jellico and LaFollette. About 250 men were working at these mines. Such was the picture of the Pruden Valley area in 1953. How could adequate medical service be provided to residents of an area so remote and so poor?

9

THE

MEANS

For a number of years the Tennessee State Medical Association had been concerned about the quality of medical care and hospital services in certain rural areas in the state. Some of these areas lacked physicians and facilities to carry on adequate medical practice. A number of factors contributed to the prevalence of medical care problems: the lack of a catalytic element to organize the community; overemphasis on hospital construction rather than on development of facilities better suited to smaller communities; the reluctance of physicians to accept isolation from the medical and social environment in which they had been trained; the individual physician's lack of capital to develop adequate facilities even when it appeared that revenue from the practice would be sufficient to support the physician and his clinical facilities. A sequence of events in 1952 gave added impetus to the endeavor to alleviate medical care problems in mining areas. Early in the year Warren F. Draper, M.D., Executive Medical Officer of the United Mine Workers of America Welfare and Retirement Fund, called to the attention of the American Medical Association the inadequacy of medical service in many mining areas. The Council on Medical Service of the American Medical Association was instructed to send a survey team to meet with representatives of the state medical societies of Kentucky, Tennessee, and West Virginia; to get in touch with the U.M.W.A. Medical Administrators for these areas and visit the area offices; and to visit as many local medical and hospital facilities in the mining areas as time would permit. 11

THE

MEANS

The purposes of these assignments were to verify the extent and types of medical-hospital problems as reported to the Council by the U.M.W.A. Executive Medical Officer and the Area Medical Administrators; to ascertain what, if anything, the American Medical Association might do to assist in alleviating such problems; and to report the survey team's findings and recommendations to the Council in a form suitable for presentation to the Board of Trustees. Β. M. Overholt, M.D., of Knoxville, Chairman of the Tennessee State Medical Association's U.M.W.A. Liaison Committee, accompanied the survey team into Tennessee area coal camps for first-hand inspection of facilities. In the Pruden Valley they found the conditions previously described. After visiting several other areas in Tennessee, the team submitted a report together with specific recommendations. The Executive Secretary of the Tennessee State Medical Association then arranged for a conference and wrote to the state U.M.W.A. Liaison Committee that "the report is of such urgency that an immediate meeting should be held to consider the recommendations of the American Medical Association Survey Team." In addition to submitting reports to the state concerned, the American Medical Association called a conference to be held at Charleston, West Virginia, September 2, 1952, "to review the recommendations of the survey team and take such steps or actions as are necessary to improve the quality of medical and hospital care in these areas." At this conference it was agreed that all participants, after studying the recommendations, should submit their comments to the American Medical Association, following which another conference would be held for further discussion and the adoption of specific recommendations. Shortly after the Charleston meeting, the Tennessee State Medical Association sent a delegation to confer with officials 12

PRÜDEN

VALLEY

of The Commonwealth Fund in New York on matters related to the establishment and financing of adequate medical facilities in Pruden Valley and other areas in eastern Tennessee. The Board of Trustees of the Tennessee State Medical Association realized that organized medicine in the state had a moral obligation to extend good medical care to all the people of Tennessee. To assure permanence and continuity of the program, responsibility was delegated to the Tennessee Medical Foundation, an organization which had been founded by the State Medical Association to (1) extend medical knowledge, (2) advance medical science, (3) elevate the standard of medical education, and (4) prevent and cure disease. (See Appendix A for the Articles of Incorporation.) The Foundation's Board of Directors appointed a Committee on Health and Medical Care, composed of representatives from many branches of medical service,* to report to the Board on medical care problems in the state. A grant from The Commonwealth Fund for use in extending good medical care to isolated Tennessee areas enabled the Foundation to employ a full-time field secretary and to establish an office in Knoxville. In the summer of 1953 a survey of Pruden Valley was madet and a comprehensive report was presented to the Tennessee Medical Foundation Board and its Committee on Health and Medical Care. A clear and concise statement of the Foundation's philosophy, plan of operation, and program objectives was formulated in preparation for the Second Conference on Medical Care in the Bituminous Coal Mine Area, held in Charleston, West Virginia, September 13-14, 1953. At this conference * Dr. Β. M. Overholt (Chairman), Internist, Knoxville; Dr. J. S. Hall, General Practitioner, Clinton; Dr. Cecil Newell, Surgeon, Chattanooga; Dr. R. H. Kampmeier, Editor of State Medical Journal, Internist, Department of Medicine, Vanderbilt University, Nashville; Dr. Daugh W. Smith, Surgeon, Nashville; Dr. R. H. Hutcheson, State Commissioner of Health, Nashville; Dr. E. G. Kelly, Surgeon, Memphis, f See Appendices C, D, and Ε for survey results.

13

THE

MEANS

Dr. Overholt stated the Foundation's "acceptance of the fundamental philosophy that organized medicine can and should assume an active role in the medical affairs of local communities and shall stand in a position to materially assist and insure the provision of good medical care to the people of the State of Tennessee." H e told of the interest s h o w e d by the various c o m m u n i t i e s in problems involved in the provision of g o o d medical service and set forth the Foundation's program to achieve the f o l l o w i n g objectives: 1. To visit the community and discuss the problems with all interested parties. 2. To investigate the resources and agencies that can be brought to bear on the problem. With data at hand, to advise and assist in local planning for an appropriate solution. 3. To assist in recruitment of physicians to fill the needs of the community. 4. To sponsor a system of specialist consultation services to rural clinics and hospitals. 5. To integrate the contribution of state public health services and voluntary community health agencies through the family physician. 6. To develop the concept of rehabilitation of the individual as an objective of the practice of medicine. 7. To extend the organized program of postgraduate training to the rural area through cooperation of the universities and available medical talent in nearby centers. 8. To encourage and assist the rural general physician to participate in special training. 9. To establish local prepaid plans where appropriate in substandard areas. 10. To encourage the Tennessee State Medical Association to develop a comprehensive voluntary prepayment program. 11. To invite labor and management to participate in the evolution of such prepayment plans for industry as will resolve their problems of medical care. 12. To encourage the development of community-sponsored, nonprofit health centers in rural areas, under the direction of a board of local citizens. 14

PRÜDEN

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13. To recommend that the health center include a dentist and at least one public health nurse. 14. To encourage medical schools to select and persuade young physicians to staff marginal area clinics for reasonable periods.

The report concluded: The quality of medical care is primarily the obligation of organized medicine. There are professional mechanics whereby we can judge the good from the bad. There are rules and regulations that go far toward assuming a high quality of service and still zealously guard the patient-doctor relationship. There are principles to which every doctor is pledged that should assure the kind of devotion the patient expects of his physician. No rule or mechanism is better than the people who make it work, but physicians can best evaluate the quality of medical care and this responsibility must be accepted by the profession. We feel that a program should be worked out for the best advantage of each local community; solutions applicable in rural Tennessee are not necessarily fitted to the metropolis of Chicago. We feel that high quality comprehensive medical care must be provided to all the people at a reasonable cost. This can only be achieved by evolving more efficient systems of providing medical care and more efficient means for paying for that care. We feel that the physician should have access to all the resources necessary for the care of the patient and that it is necessary to develop team-work, not only of medical components but of lay and community elements, in order to achieve this purpose. We feel that our State Medical Association has assumed only that responsibility which it should rightfully bear to the people it must serve.

Additional concrete evidence of the interest in and support given the Foundation's program by the State Medical Association came at a meeting of the House of Delegates in Nashville in 1954 when the following resolution was adopted: Be it resolved, the House of Delegates of the Tennessee State Medical Association: 1. That the Board of Trustees of the Tennessee State Medical Association be hereby instructed to make available to the Tennessee Medical Foundation funds up to $10,000 for the purpose of underwriting the Foundation's efforts to provide adequate medical care for 15

THE

MEANS

those areas or communities deemed in critical need of medical care by the Foundation; and 2. That the Board of Trustees be hereby authorized to provide the above funds out of the Investment Fund of the Association; and 3. That the funds authorized in the Resolution shall be repaid to the Tennessee State Medical Association when and if the financial resource of the Foundation permit.

The Commonwealth Fund was petitioned for an additional grant, since the original money was allocated for only one year of operation, and the Fund agreed to help in underwriting the Foundation's budget for eighteen additional months. At the time of the Third Conference on Medical Care in the Bituminous Coal Mine Area in the fall of 1954, representatives of the Tennessee State Medical Association could make an encouraging report about the progress of the Foundation's activities. The conference unanimously approved the following resolution expressing its interest in and high regard for the work of the Tennessee Medical Foundation: The Third Conference on Medical Care in the Bituminous Coal Mine Area has heard with great interest reports from Tennessee concerning its program for bettering medical care in low income sections of its coal fields. The work done in these areas serves the entire profession as a pilot project in cooperation between organized medicine, state health department, a labor union sponsored health program, medical schools, and local communities. The progress made in meeting the health problems of marginal income areas reflects credit on the medical profession of Tennessee. It benefits the entire medical profession by its favorable effect on public opinion. Therefore, be it resolved by this Conference that we congratulate the State of Tennessee on its accomplishment and express our sincere appreciation for the expenditure of time and effort which has gone into it.

16

THE

APPROACH

It was obvious that many problems would have to be solved. The first was the provision of suitable office or clinic space, which would have to be made available before any qualified physician could be persuaded to move to the area. Four buildings were available, any one of which could be made reasonably satisfactory at moderate cost. The plan was to have the residents of the area provide the building, with the understanding that the clinic would be managed by the doctor according to policies determined by a local committee or council. It was to be, in fact as well as in name, a community clinic. The ultimate goal was the improvement, through community organization, of living standards in the area — better gardens, diet, sanitation, health education, recreation, libraries, school facilities, etc. Steps were taken in the fall of 1953 to get better information about the people and their health problems, and to determine what agencies outside the area could be induced to interest themselves in the problems of the Valley. The Field Secretary made contacts with regional offices of the State Health Department, the State Planning Commission, and the State Conservation Department; a number of colleges and departments of the University of Tennessee; the president and several faculty members of Lincoln Memorial University; various divisions of the Tennessee Valley Authority; and virtually all of the county officials of Claiborne and Campbell Counties, Tennessee. From these visits in the field and agency contacts he became aware of many widely diverse problems. 17

THE A P P R O A C H A house-to-house survey of 1,000 families living in the Valley was undertaken. A number of sociologists, economists, and health education specialists of the Tennessee Valley Authority, the University of Tennessee, Vanderbilt University, and the state and local health departments assisted in preparing a survey questionnaire (see Appendix B ) . Three local teachers were assisted by a graduate student of the University of Tennessee in getting the survey under way. Arrangements were also made with the State Health Department to furnish two nutritionists to conduct a survey of nutrition, diet, and eating habits of school children of the fourth, fifth, and sixth grades. The survey provided a fairly good picture of the Valley, its problems, and its possibilities. After thoughtful consideration, the Foundation decided to go ahead with plans for the establishment of a clinic despite the fact that the economic picture was not bright. In the early part of 1954 an abandoned commissary building at Valley Creek was selected as the site for the clinic. Valley Creek is approximately two miles southwest of Prüden and less than one mile from the main highway running through the Valley. Although this building was not in the exact center of the area, it was within eight miles of the most distant part of the Valley. The building was substantial, in good condition, and equipped with electric lights and a pressure water system. It would be necessary to add sanitary facilities and partitions, and to do some general repair work and repainting. The Pruden Coal and Coke Company agreed to lease the building for one year for one dollar, with the understanding that the Foundation would assume responsibility for making the necessary renovations and alterations. The lease provided that if the program should not work out satisfactorily the building was to be vacated at the end of one year in better 18

PRÜDEN

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condition than when it was leased, but that if plans should work out as anticipated, the Foundation or a local committee could continue to rent the building after the first year at $50 a month. When contributions were sought to buy materials for renovating the building, one individual pledged $50 and suggested several others who might be willing to contribute. It seemed advisable to start work on the building at once in the hope that visible progress would stimulate public interest. Accordingly, when only three donations were in hand, materials were purchased and the work started through contributions of unpaid labor. The floor was successfully sanded although only three men in the entire area professed any knowledge of this kind of work. A young minister laid off partitions and set up framework for the offices. Although, as had been hoped, the actual construction did arouse more interest, there was still a problem of strategy to be solved. People up and down the Valley would ask the Field Secretary: "How is your clinic getting along?" or say: "I will help you with the clinic." It was obvious that he was being cast in the role of promoter," a situation which was not desired. To counteract this attitude the decision was made to organize a local building committee to assume full responsibility for renovations. Officials of the U.M.W.A. Welfare and Retirement Fund office in Knoxville and the district union office at Middlesboro, Kentucky, agreed to name at least one person each from Fonde, Pruden, and Clairfield to serve on such a committee. A field representative of the U.M.W.A. Welfare and Retirement Fund accompanied the Field Secretary to the Valley and talked with the three men who had been recommended. Two of them were interested in the project and willing to work; the third was uncertain. In addition, contacts were made with the superintendent of a coal company at Clairfield, a retired 19

THE A P P R O A C H business man, a young minister, and an electrician of Prüden. With one exception, all agreed to serve on the committee. The committee had some difficulty in functioning as a team, however. The secretary-treasurer soon had to leave the Valley to secure employment, and the chairman became over-burdened with work and unable to keep close contact with committee members. At this critical time an event occurred which did a great deal to build morale and weld the committee together. A member of the committee called on the County Judge*, who agreed to present a resolution at the next court meeting which would provide financial assistance for the clinic. The approved resolution provided $500 and enabled the committee to buy supplies and complete the renovation of the building. While the problem of providing quarters for the clinic was being solved, the equally pressing problem of financing its operation was receiving attention. The superintendent and officials of the coal company at Fonde, the first to be consulted, expressed keen interest but stated that irregular work and small profits made it impossible for the company to put money into the project. It soon appeared that the miners themselves, rather than the operators, would have to take responsibility for whatever was to be done. This was not an unusual or unexpected situation. Until some twenty years ago, miners were often exploited by the coal mine operators, although there were operators who were sincerely interested in helping miners and their families. Such help, however, was largely of a paternalistic nature. If a miner was friendly, * In Tennessee the county is the important local political unit, and the county court is a quasi-legislative body made up of elected representatives from the civil districts into which the county is divided. Members of the county court are known as "squires" and locally exercise the functions of peace officers as well as those of political leadership. The chairman of the county court, known as the county judge, is an administrative officer. In Claiborne County the court is made up of 22 members, two of whom represent the portion of the county in Pruden Valley.

20

PRÜDEN

VALLEY

agreeable, and willing to work, the operator would extend favors, carry him on the books for food and living expenses, and otherwise help him over rough spots. As the unions became stronger, relations between operator and miner changed. The operator became an adversary, and negotiations between operators and unions on such matters as wages and working conditions sometimes led to bitter controversy. As time went on, miners more and more turned to district headquarters of the United Mine Workers of America for help in solving their problems. The local unions in the Valley began to discuss the feasibility of directing their medical "cut" (deductions from wages for prepaid family physician care) to the proposed clinic, and reports from labor leaders indicated that a majority of the miners would authorize such a "cut" if the clinic should be established. In 1953 about 600 residents of the area were working in coal mines. It was estimated that if even half that number would authorize monthly prepayment of $4.00 each, adequate funds would be available to secure one doctor immediately and possibly an additional doctor later. At this point, another difficulty arose. The local unlicensed "doctor," who had many friends and relatives in the unions, was closely tied to an influential faction. As long as the proposed clinic did not threaten his income, he was not openly hostile, but when the locals began discussing prepayment to the clinic, an open break occurred. One faction charged that the clinic proposal was merely a device to drive the "doctor," who was well known and liked by local people, out of the Valley, and they chose to back him rather than a new-fangled clinic plan sponsored and promoted by "outsiders." Other residents feared that if the former "doctor" were to be replaced the Valley might be left without any kind of medical care in case the clinic should be unable to continue. The members of one of the local unions voted not to pay the new clinic but 21

THE A P P R O A C H to try to work out some way to continue to support their "doctor." The local squires at first had been enthusiastic and had pledged their full support of the clinic, frankly saying that the local "doctor" was not certified to practice medicine. The first indication of a change of attitude on their part came when one of them asked whether a compromise could not be worked out whereby the former "doctor" would handle "the small cases" for the clinic while the new physician would deal with the major medical problems. The Foundation refused to participate in a plan which would include the use of the unlicensed "doctor." Another problem threatened the whole project. The mines at Fonde, Pruden, and Clairfield, and the New Jellico mines on White Oak Mountain discontinued operations. The Virginia-Jellico Coal Company at Clairfield surrendered its lease, and the superintendent, a member of the clinic building committee, was transferred to Kentucky. In spite of these difficulties, the renovation of the building, the solving of financial problems, and the development of plans for better health service progressed. Discussions were held with school officials concerning the need for a dentist to examine children's teeth and to do remedial work. The School Superintendent of Claiborne County agreed to defray a portion of the cost of such a program if the State Department of Health and the Tennessee Medical Foundation would procure a dentist and help pay the cost. Donations from a number of dental supply houses and manufacturers provided a tooth brush for each school child. The teachers were supplied with a chart showing how to brush the teeth. Interest in better dental care was generated through meetings with the teachers and talks to the children. In the late summer of 1954 dental equipment was procured and arrangements were made for a dentist to visit the clinic each 22

School a n d p l a y g r o u n d at E a g a n .

THE Wednesday.

APPROACH A number of trips and considerable work by

the building committee were required to get the equipment installed. The initial response of the public to this new dental service was disappointing. Not one patient showed up the first Wednesday, two appeared the second Wednesday, and the increase thereafter was discouragingly slow. The task of locating a physician willing to live and work under conditions found in the Valley was not simple.

The

members of the Foundation's Board exhausted their immediate resources without success, but finally the Assistant Dean of the University of Tennessee College of Medicine recalled a friendship with a former student's father and through him a doctor for the Valley was found. Dr. David Meek, a graduate of the University of Tennessee College of Medicine who had recently completed his internship, agreed, after visiting the area, to take over the operation of the clinic for at least a year pending an expected call for military service.

With a part-

time dentist on the job and the doctor scheduled to arrive in August, 1954, there was a noticeable change in the attitude of the residents: Skepticism was replaced by interest and confidence. Financial problems continued, however.

With less than

$1,500 in its treasury, the Foundation experienced difficulty in getting the necessary equipment.

A t this point members of

the Foundation's Board and the Committee on Health and Medical Care were particularly active. A lend-lease arrangement for the use of a quantity of army surplus medical equipment was negotiated, free drugs were secured, and individual doctors contributed equipment.

Used x-ray equipment was

purchased from the widow of a deceased physician and turned in for credit to apply toward the purchase of a better instrument. Many other groups and individuals provided assistance. The Tennessee Federation of Women's Clubs, Mountain Division, 24

PRÜDEN

VALLEY

donated $600 a year toward the services of a public health nurse. Arrangements were made with the state and local health departments to conduct physical examinations, inoculations, and tuberculin tests for school children of the area. When Dr. Meek arrived he found that, with the exception of a shortage of drugs, the clinic was ready to start operation. The wife of a missionary Baptist preacher in the area had been selected to assist him in the clinic. Her understanding of the local social and political structure proved particularly helpful. The clinic's first patient, suffering from a sty, underwent a minor surgical procedure to obtain relief. Later Dr. Meek remarked: "The patient's gratitude was a wonderful thing." The first home visit was to a patient with gastroenteritis. Fortunately, Dr. Meek had a sample drug which alleviated the patient's distress. As a result of this experience, Dr. Meek immediately made arrangements for supplies of drugs to be kept at the clinic. It soon became evident to Dr. Meek that, in dealing with the Valley people, the patient-doctor relationship was not the same as that encountered during his internship. As he stated: "I reluctantly but necessarily had to recognize that the simple trust and cooperation accorded me as an intern had come to an abrupt end and that my present patients were suspicious and uncertain of my capabilities in addition to being saturated with many antiquated viewpoints on medical therapy." Shortly after the clinic began to receive patients, an elderly woman approached Dr. Meek and asked for fifty cents worth of "nerve pills." This incident brought to light the local custom of self-diagnosis and treatment which had been condoned by previous physicians and pseudo-physicians. After a great deal of coaxing and arguing, the patient agreed to submit to physical examination and diagnosis of her condition. Another instance of this custom of self-diagnosis occurred soon after the 25

THE

APPROACH

clinic opened. Dr. Meek was called in to see a young girl who for five days had been treated for lobar pneumonia on a sendthe-medicine basis by a local "practitioner." It is scarcely surprising that her condition had not improved. Proper treatment by Dr. Meek relieved her difficulty. If the former medical care of patients with acute illnesses could be rated only as poor, the diagnosis and care of chronic or recurrent illnesses had been pitifully inadequate. Dr. Meek saw many persons who were unnecessarily crippled and heard of many needless illnesses which would not have occurred had adequate medical care been available. Unfortunately he was not always able to overcome patients' suspicions or religious convictions and persuade them to undergo corrective care and surgery. The most touching medical poverty was found among the children. Many of them were allowed to become seriously ill before the parents would bring them to the doctor. Complications following tonsillitis and upper respiratory infections often occurred before medical therapy was sought or instituted. As a result of dietary practices, many children showed active or old evidence of malnutrition. Scurvy and rickets were commonplace. The importance of vitamin therapy in infancy and early childhood had to be continually stressed. It was most gratifying to see the dramatic improvement of many poorly nourished and underfed children when they were given proper food. Pyorrhea was almost endemic. Decay of the teeth far beyond normal was possibly related to high carbohydrate diet, frequent use of carbonated beverages and tobacco, and lack of prophylactic dental treatment. Dr. Meek found medical practice in the Valley interesting and often very gratifying, but poverty, ignorance, and superstition made it extremely difficult to practice the type of medicine which he had been taught as an intern. However, as he 26

PRÜDEN

VALLEY

became better acquainted with the people and developed a background for understanding the social structure, the earlier suspicion he had found in many of the residents, the antagonism on the part of those who had been loyal to the previous "practitioner," and the difficulties caused by the practice of selfdiagnosis began to diminish. Six months after the clinic opened, a public health nurse arrived. Her acceptance by the population was immediate and she was helpful in innumerable ways — taking care of patients, making home visits, and carrying out health education activities. Prior to the arrival of the public health nurse, immunization had been almost unknown, but with her assistance a large number of children were immunized against diphtheria, tetanus, typhoid, and whooping cough. Before this could be done, however, whooping cough became epidemic. It would be impossible to say to what extent chronic bronchial diseases and pulmonary disorders had their start in protracted cases of whooping cough. In the mining population pulmonary diseases, including tuberculosis, were thought to occur with far greater frequency than in the average population, and it was extremely difficult to direct therapy for those with chronically diseased lungs. Emergency surgery was largely confined to minor conditions, although emergencies occasionally required procedures for which the clinic was not equipped. Each surgical case among the indigent patients posed a major problem, but cooperation by the Middlesboro (Kentucky) Hospital and various hospitals in Knoxville enabled the clinic to secure satisfactory treatment for most of these cases. With the aid of the State Crippled Children's Services and the Tennessee Division of Vocational Rehabilitation, it was possible to eliminate part of the tremendous backlog of chronic disabilities which were amenable to therapy. Obstetric practice in the area provided excitement and 27

Clear Fork Community Clinic.

Clear Fork Community Clinic: office a n d h a l l w a y a s seen from reception room

Clear Fork Community Clinic: recovery room a n d nursery.

THE

APPROACH

drama. A very interesting and difficult case was described by Dr. Meek: A few days before Christmas my clinic assistant and myself were summoned on a labor case. We traveled several miles over snowcovered roads to meet a jeep which drove us the rest of the way up the mountain. After transferring our equipment to the jeep we literally hung on for dear life as we traversed the trail which would have made for poor travel even under good weather conditions. We found the patient in a log house situated on the edge of a mountain top and exposed to subfreezing winter winds. We looked forward to entering the warmth of a cabin. However, we soon discovered that there were cracks large enough to admit small animals. The delivery was extremely complicated with a frank breech presentation, but after much blood, sweat, and tears and a word of silent prayer, the mother was delivered of a healthy female child. The delivery was accomplished after nightfall, and the only lighting equipment consisted of one small chimney kerosene lamp and a flashlight. This was perhaps my first introduction to medicine in the rough, and it was an experience which I wish to duplicate as infrequently as possible. However, the mother and child did well, and I made two post-partum visits over the same snowy, icy trail to make sure that mother and infant enjoyed a normal course.

Experience in home deliveries led to a search for a safer method for delivering these patients. The decision was made to set up a delivery room at the clinic. Within eight months approximately 40 babies were delivered there under reasonably adequate sanitation and lighting and with necessary equipment available. Obstetric practice probably had been the least adequate of the inadequate medical services in the Valley before the clinic opened. Women had frequently experienced multiple lacerations during the first and second home deliveries. No attempt had been made to repair these lacerations, and as a result many women had multiple pelvic muscular relaxations. With facilities for spinal anesthesia and local anesthesia, the physician was able to carry through the obstretric practice of episiotomy. On several occasions forceps were used advantageously. 30

PRÜDEN

VALLEY

In no community is the situation completely static. When one of the smaller of the ten hospitals constructed under the auspices of the U.M.W.A. Welfare and Retirement Fund was opened at Middlesboro, Kentucky, in November, 1955, Dr. Meek was made a member of the visiting staff and, despite the distance, he transferred most of his obstetric deliveries to that hospital instead of taking care of them in the clinic. By 1955 the widespread depression in the coal mining industry had made a tremendous impact on the Valley residents. Even the few mines which continued to operate offered limited employment. Those who had been retained were from the older age groups. The unemployment of most miners in the productive 25 to 45 age bracket resulted in their exodus from the Valley. This left the Valley population with a rather unusual age distribution. The older age group, which included many men who had retired or soon would retire from their mining careers, manifested a high incidence of the diseases of aging and of pulmonary diseases. In spite of the economic depression in the Valley, the use of the clinic's services steadily grew, demonstrating that people will make use of good medical care when it is available. During the first twelve months Dr. Meek made charges for 3,988 patient visits, 628 of which were in the last month, and collected $7,418. The unqualified practitioners in the area were unable to compete with highgrade medical service and voluntarily decided to leave. By the end of the eighteenth month, Dr. Meek's service charges equalled the income which had been guaranteed him by the Foundation. Widespread interest was aroused by the Pruden Valley project. Soon after Dr. Meek arrived, Lije Magazine sent two representatives to the Valley to interview citizens and to take pictures. The story appeared in the November 29, 1954, issue of the magazine. No accurate and detailed record has been kept of the total 31

THE A P P R O A C H cost in time and effort of the Prüden Valley project. Between August 1, 1953 and January 31, 1956, The Commonwealth Fund contributed a total of $39,400 toward the expenses of the Tennessee Medical Foundation in the employment of a full-time field secretary, travel by the secretary and Foundation members, stenographic service, the collection of information, etc. It is estimated that from one-third to one-half of this expense may be charged to Pruden Valley. The Tennessee State Medical Association made $10,000.00 available to the Foundation as a revolving fund for the purpose of underwriting the Foundation's efforts to provide medical care for those areas deemed in critical need. The work of the Foundation was to some extent assisted by the U.M.W.A. Welfare and Retirement Fund, which also contributed a generous amount of time of its staff. Further contributions during the first year were made by consultants from Knoxville who waived their fees for 84 trips to Pruden Valley and other areas. The total thus saved was considerable. In anticipation of the need to find additional income to support the field secretary after the exhaustion of the Commonwealth Fund appropriation, a drive in 1955 netted something over $8,000 from the 650 physicians who subscribed to membership in the Tennessee Medical Foundation. Contributions of time and money toward the renovation of the clinic building by residents of the Valley were estimated at more than $3,000. The Tennessee Federation of Women's Clubs, Mountain Division, pledged $50 a month toward the salary of the public health nurse assigned to the area. The Benwood Foundation, Inc., of Chattanooga made $10,000 available to help in underwriting the program, and various other contributions of services, drugs, equipment, etc. over an eighteen-month period were estimated at $5,000. It was understood from the time arrangements were first made with Dr. Meek that, because of other long-range plans, 32

PRÜDEN

VALLEY

he would not remain in the Valley indefinitely. At present the medical service is being operated on a part-time basis. Pending recruitment of a full-time physician to replace Dr. Meek, the Foundation has arranged for an internist to have regular clinic hours two days a week.

33

La Follette Community Hospital.

OTHER

PROJECTS

The Pruden Valley story has been told in considerable detail because it was the most spectacular project of the Tennessee Medical Foundation, but at the same time other communities, chiefly in the eastern part of the state, were being helped in their efforts to secure better medical service. The nature of this help varied from community to community depending upon local needs and conditions. Sometimes representatives of the Foundation discouraged community aspirations for the building of a small hospital, when it appeared more practical to set up a small clinic and depend on larger hospitals not too far away for the care of the more serious cases. On the other hand, when needs and means called for the building of a hospital, the Foundation was ready to assist the community in carrying out its plans. Partly because of the flexibility of the help it was prepared to give, the Foundation proved to be a useful agent for carrying out the wishes of the State Medical Association to improve medical service in areas which were substandard from the viewpoint of health. The more important of these other projects will be described briefly to indicate the various problems found in different communities and the ways in which the Foundation helped to solve them. Wartburg

Area

Wartburg, which has a population of 800 and is the county seat of Morgan County, lies in the heart of a prosperous farming community. Although the people of the county have a 35

OTHER

PROJECTS

higher average income than those of some of the other rural counties in eastern Tennessee, the medical service available left something to be desired.

Only one new physician had

come to the county in the preceding twenty years.

In 1953

an elderly doctor and his son had an office in Sunbright, 12 miles north of Wartburg, and a 63-year-old physician had an office practice in Oakdale, 12 miles south. In Wartburg there was only one physician, aged 67, w h o had contract practice for two mines and did limited office work in his own home. There was no dentist in the county, and everyone needing dental care had to travel f r o m 18 to 45 miles to get it. Hospital care was available at the 52-bed Harriman Hospital, 16 miles away; at the 200-bed Oak R i d g e Hospital, 25 miles away; and at the four large Knoxville hospitals, 42 miles away. Initially, the Tennessee State Medical Association was asked to offer counsel and guidance to the community concerning its medical care problems.

Subsequently a conference was

held in Wartburg which was attended by representatives of the State Medical Association, the State Public Health Department, and the community. Members at the citizens' committee said they hoped to have their share of Hill-Burton matching funds applied to a small hospital or a clinic with six or eight recovery beds.

I t was

the opinion of the professional representatives, on the other hand, that the community needed a good general practice facility rather than a hospital.

T h e citizens' committee had

tried unsuccessfully to obtain a physician and was unanimous in its opinion that responsibility f o r providing a clinic doctor should rest with the Tennessee State Medical Association. Later, representatives of the Tennessee Medical Foundation, the State Medical Association, and the U . M . W . A . W e l fare and Retirement

Fund

appeared

before

the

Morgan

County Fiscal Court to discuss trends in medical care f o r areas 36

W A R T B U R G AREA

comparable to Wartburg and Morgan County. The court then appointed a committee composed of the county school superintendent as chairman, the county judge, and three members of the County Court, to study further the problem of providing better medical services and to report and make recommendations to the court at its next quarterly meeting. The Foundation's Committee on Health and Medical Care agreed to work with this local committee. Representatives of the Foundation, the State Medical Association, and the U.M.W.A. Welfare and Retirement Fund attended the full County Court meeting to answer questions regarding the county's health and medical needs. The recommendation of the committee appointed by the court was fully discussed, and the court unanimously passed a resolution to appropriate $35,000 for a clinic building. The major portion of this sum consisted of various unexpended balances which had been set aside for repairing and renovating the courthouse. The members of the court agreed with members of the committee that the community's need for a clinic outweighed the need for improvements in the courthouse. The court then directed the committee to determine the type of building needed and to bring building plans to the next meeting of the court for final approval. To assist the local group, the Committee on Health and Medical Care secured plans of clinics that had been built elsewhere, and took the members of the local committee on a trip to see a clinic in operation in a neighboring state. In January, 1954, the local committee reported on the building site selected and submitted drawings of the proposed building to the Fiscal Court. The court accepted the recommendations and directed the committee to proceed with the preparation of the detailed plans and specifications and to submit them for public bids. Following completion of the clinic, a young graduate of 37

OTHER

PROJECTS

the University of Tennessee Dental School opened his office in the building. Within a few weeks he had more patients than he could accommodate and had appointments booked two months in advance. However, he still reserved a part of each week to provide dental care for school children in connection with the state dental health program. Six months later the dentist purchased $10,000 worth of equipment to add to the Fiscal Court's initial outlay of $3,500 for dental equipment. A young physician came to the clinic in October, 1954. Within three months he was seeing 25 patients a day. He expressed satisfaction with the development of the patient load and felt that his collections had been good. Courtesy privileges were accorded him at the hospitals at Harriman and Oak Ridge. The doctor and the dentist were well received and the clinic has become an integral part of community services. During the first year of operation there was no rental charge on the building or on the equipment, but thereafter a nominal rent was collected to enable the county to amortize the original investment. The Morgan County Court, with the advice and counsel of representatives of the Tennessee State Dental Association and the Tennessee Medical Foundation, has demonstrated that better medical care can be achieved through cooperative community effort. LaFollette

Area

In the LaFollette Area, the Tennessee Medical Foundation gave assistance at a much higher level of medical and health service than in the Pruden Valley area. LaFollette is a pleasant and picturesque community with a population in 1953 just short of 6,000. The city is centrally situated in Campbell County, which had a population of nearly 35,000. It is 26 miles from Oak Ridge and 44 miles from Knoxville, where excellent hospital facilities and specialty care are available. 38

LA

FOLLETTE

AREA

At the time of the 1953 survey, medical and dental care was provided by 10 general practitioners and 3 dentists. There were two proprietary hospitals, one with 17 beds and the other with 22 beds. Both had closed staffs. One was owned by a doctor and his wife, and the other by a small group of physicians and a nurse. Following the 1952 visit to the LaFollette area by the American Medical Association survey team, the Tennessee State Medical Association gave advisory service to the community. The need for a modern hospital was apparent. Various attempts to develop a community hospital had failed over a number of years. These had aimed at a county-sponsored hospital, but the proposals were defeated by sectional rivalries in the county and by the reluctance of the proprietary hospitals to make concessions. Eventually city officials and physicians agreed upon a community hospital with open staff, and the proprietors promised to close the two existing hospitals. Representatives of the Tennessee Medical Foundation met with local officials a number of times during this planning stage. With an allocation of Hill-Burton funds and the approval of a local bond issue by a vote of four to one, total funds approximating $570,000 were made available through local, state, and federal sources for the construction of a 43-bed hospital. The city council agreed to assume the expense of operating the hospital for twelve to eighteen months until a sound operational program could be developed. The Foundation assisted the community in securing a well-qualified administrator and helped to orient members of the hospital's board as to their duties and responsibilities. The hospital began operations in the summer of 1956. The Foundation has arranged for regular consultant visits in the fields of pediatrics and internal medicine and will extend this service to include other medical specialists when the need arises. 39

PALMER

AREA

Palmer Area The Palmer area, commonly called the "Pocket," in southeastern Tennessee some 40 miles northwest of Chattanooga, includes a segment of Sequatchie Valley and a rim of the Cumberland Plateau region in the eastern part of Grundy County. Its population of 7,500 is scattered over an area of 300 square miles. The village of Palmer, itself, has a population of slightly under 1,000. In 1953 one young general practitioner owned and operated a combination clinic and 8-bed hospital in Whitwell, 14 miles southeast of Palmer. Altamont, 14 miles away in a northwest direction, had a general practitioner with offices in a 12-bed hospital. Excellent hospital facilities and medical specialists were available in Chattanooga, 42 miles away. Hospital care was also available at Sewanee, 25 miles southwest of Palmer. For several years the residents of this community had discussed the possibility of building a local medical facility. During the early part of 1953 four of the local coal mining unions agreed to work toward the goal of building and operating a hospital for its members and pledged financial help and free labor. The group experienced difficulty in securing an adequate amount of money and in selecting a suitable location for a building. The Tennessee Medical Foundation was asked for assistance in crystallizing ideas and formulating a practical plan of action. As a first step the Foundation provided medical and dental survey forms to obtain a clear picture of medical care problems and to learn where individuals in the area were going for treatment. The survey was carried out by local citizens and the completed forms were sent to the Foundation field office for tabulation and interpretation. At the time of receipt of the survey results, the building committee chairman informed the Field Secretary that the people of the area were primarily interested in a combination 41

clinic and 8- or 10-bed hospital. He said the coal company had agreed to donate a plot of ground in Palmer as a building site, clear the land, and use their purchasing power to secure building materials at a discount. Over $3,000 had been pledged by local citizens for the project. Several men offered to donate labor, and a number of truck owners volunteered to haul gravel, sand, and other building materials. Although no building plans or specifications had been prepared, there was a definite intention to build in the spring. A meeting was held which included doctors from Marion and Grundy counties, members of the local building committee, and representatives from the Foundation's Board, the U.M.W.A. Welfare and Retirement Fund, and the Tennessee Department of Public Health. Following discussion of the medical needs and resources of the community, it was agreed that a clinic was needed and could be financially supported. An architect visited the suggested site and tentatively approved it as an acceptable location. A contour survey was made by the coal company, and the State Health Department checked the water supply and the sewage disposal field and found both to be satisfactory. Arrangements were made for the preparation of a floor plan which was acceptable to the building committee. Originally the plan provided space for one doctor and a dentist but was later revised to make provision for an additional doctor. Incorporation of the town of Palmer enabled the community to secure gasoline and sales tax turnback money from the state. The City Council then allocated part of the sales tax money to clinic construction. A short time later a special census was taken which resulted in an increase of the tax turnback. Two members of the building committee, elected to the County Court, succeeded in obtaining an appropriation of $2,000 to be added to the citizens' subscriptions of $3,000 for the clinic. More individual contributions were 42

DECATUR AREA received and a number of coal miners offered to have a contribution made from their wages each month for one year. The coal company agreed to the cutting of timber from its property to provide lumber for the building, and local men donated their labor to cut, saw, plane, and stack 10,000 board feet of lumber on the building site. Although innumerable problems had to be overcome, the building was dedicated on September 3, 1956. The Foundation assisted in staffing the clinic and has offered to arrange for consultant service as needed. The clinic actually accepted its first patient on the day of the arrival of a physician, although the building was not yet completed. Decatur Area Decatur, a town with a population in 1953 of only 235, is nevertheless the county seat of Meigs County, which had a population of just over 6,000. In 1953 there were no fulltime doctors or dentists in the entire county; one elderly doctor had been semi-retired for five years. The nearest physicians and hospitals were at Athens, 12 miles from Decatur, and at Sweetwater, 28 miles distant. A licensed pharmacist owned and operated a small drug store in Decatur. The medical needs of this community came to the attention of the Foundation through a retired general practitioner who had been unsuccessful in his efforts to get the County Court to provide money for the construction of a community clinic which might attract a young doctor. The Field Secretary of the Foundation interviewed various business and professional leaders in the community, all of whom agreed that a young doctor would be most welcome and that he could make a good living there through his practice. The Lions Club was particularly interested. At a dinner meeting, the Foundation's Field Secretary outlined various problems that might be encountered in the effort to get a doc43

OTHER

PROJECTS

tor, and emphasized the need to obtain local support for the provision of adequate physical facilities for a community clinic. Later the president of the Lions Club contacted a young doctor who agreed to practice in the community provided suitable office space could be made available at reasonable cost and assistance given in securing necessary medical equipment. Four members of the Club offered to underwrite the major cost of the equipment with the understanding they were to be repaid by the doctor from the clinic income. The local pharmacist agreed to build a suitable office, and the Tennessee Medical Foundation prepared a simple floor plan which was approved by the doctor and the builder. The Foundation also offered helpful suggestions about equipment and effected considerable savings by calling the young doctors attention to good secondhand equipment which had been offered for sale by another doctor. The clinic was opened in October, 1955. The local citizens are well satisfied with their new doctor and he in turn is pleased with the way in which his practice has developed. Tellico Plains

Area

Tellico Plains, an incorporated community of something over 800 individuals, is located in Monroe County, which has a population of nearly 25,000. In the early part of 1955 limited medical care had been provided by two elderly general practitioners who were in poor health, but in July, 1955, two young physicians from Sweetwater, Tennessee, 24 miles away, began to provide part-time medical care to the community by means of alternating afternoon visits. Although this service was helpful, the community felt that it needed at least one full-time resident doctor and a community hospital. A hospital association, incorporated in memory of a local resident, had purchased all the equipment from a 20-bed hospital. Part of this equipment was in storage and the rest was temporarily 44

ONEIDA

AREA

loaned to the two young doctors who were rendering part-time service. The nearest hospitals with ten beds or more were at Sweetwater, 24 miles distant, and Athens, 32 miles away. The young doctors said that if a full-time physician could be secured they would be quite willing to discontinue their limited service. Although their practice was still unprofitable they thought that eventually it would provide a modest living. One of the physicians thought the community could support good clinic facilities but felt that it would be unwise to construct a hospital. Representatives of the Foundation met with members of the local building committee which had been appointed to develop plans for a hospital. They pointed out many of the problems involved in the operation of a 12-bed or 15-bed rural hospital, and emphasized that a clinic with good x-ray and laboratory facilities would take care of a large part of the medical services needed, inasmuch as adequate hospital care was available within a radius of 25 to 30 miles. Later the Field Secretary arranged for members of the committee to visit the community clinic at Wartburg, examine the facilities, and talk to the young doctor and dentist. This physician also recommended construction of a clinic rather than a hospital. After a great deal of planning a ground breaking ceremony for a medical facility was held in October, 1956. Oneida Area In 1953 four physicians were practicing in Oneida, on the Cumberland Plateau approximately 70 miles northwest of Knoxville. A combination office and 8-bed clinic provided facilities for routine obstetrics and the handling of minor surgical and medical problems. More serious cases had to be taken to hospitals 60 to 70 miles distant. Early in the spring of 1954 a group of businessmen in the county met to discuss the community's need for a hospital 45

OTHER

PROJECTS

and a short time later formed a corporation to acquire a building site. Donations amounting to $24,000 were obtained and the County Court agreed to a bond issue to finance construction of the hospital. A 40-bed hospital was completed in December, 1955, and received its first patient the middle of the following month. The Foundation's Committee on Health and Medical Care assisted the building committee in solving various problems that arose from time to time. One of the local physicians recently remarked: On the surface it would appear that the Tennessee Medical Foundation had little to do with the existence of the hospital, but actually they played a large part in helping us overcome a number of problems. They also gave us valuable advice on what to include in our by-laws and our aims for our institution, but more than that, they encouraged a well-qualified surgeon to move to our community. In addition they aided us by arranging for regular specialist visits to the hospital. All of these activities have helped to improve the standard of medical care in this area.

46

SUMMARY

There are no means whereby man can accurately evaluate the full impact of an idea, but the achievement of an organization can be measured in terms of the good accomplished in the endeavor to change the course of events. In terms of time, permanence is the only monument to successful endeavor and action. The principal achievements in the thirty months of actual operation of the Tennessee Medical Foundation's program may be summarized as follows: 1. Pruden Valley has been helped to secure effective diagnostic and treatment service to replace the inadequate medical service previously available to this community. The service is being operated on a part-time basis at the moment, but efforts to find a full-time physician to replace the original doctor continue. 2. The people of the Wartburg community have been encouraged to provide a modern diagnostic and treatment clinic offering good medical and dental care rather than follow their original plan to build a small hospital. The Foundation actively assisted in the planning of the clinic and was instrumental in getting a doctor and a dentist to provide full-time medical and dental services. A successful cooperative dental program is now operating. The institution of these local services was directly responsible for the building of a modern drug store and the employment of the only registered pharmacist in the county. The purchase of several thousand dollars' worth of additional medical and dental equipment further attests to the success of this service. 47

SUMMARY

3. The city of LaFollette has been helped in developing a 44-bed Hill-Burton hospital to replace outmoded proprietary institutions. The Foundation assisted in securing a qualified hospital administrator and has aided in the orientation of the hospital's board as to its authority, duties, and responsibilities. A consultant program has also been initiated through the cooperative efforts of the local doctors, the hospital, and the Foundation. 4. The people of Palmer have been guided to develop a clinic rather than build a small hospital and have been assisted in securing professional and auxiliary personnel. 5. A close working relationship with the Lions Club and other community leaders of Meigs County has resulted in the establishment of a doctor's office staffed by a well-qualified general practitioner, the only one in the county. The Foundation aided the young doctor in preparing an office floor plan and determining minimum equipment needs, and arranged a field trip to the Clear Fork Community Clinic in Pruden Valley to enable the doctor to get first-hand information about community clinic practice and experience. 6. The people of Tellico Plains have been similarly aided in thinking through their problem and have been guided toward a modern diagnostic and treatment facility. The Foundation will continue to offer advice and counsel as needed. 7. The community of Oneida has been assisted in the organization of the board and medical staff of the new 42-bed Hill-Burton hospital and in integrating consultation services of medical specialists in the medical service offered to the people of that community. 8. An active and continuing program of public relations has been carried on to acquaint the medical profession and the public with the objectives and accomplishments of the Foundation. Numerous media of communication have been utilized. 9. A membership drive, which has already resulted in 650 48

THE T E N N E S S E E

MEDICAL

FOUNDATION

medical memberships in the Foundation, is being continued. The majority of the chapters of the Women's Auxiliary to the Tennessee State Medical Association have subscribed to organizational memberships. In addition, they are assisting in securing individual memberships among doctors. Dr. Warren F. Draper, Executive Medical Officer of the U.M.W.A. Welfare and Retirement Fund, made several prophetic remarks at the time the Foundation's program was outlined: If the Tennessee Plan becomes a reality, it will set a most persuasive pattern which other state medical associations, schools of medicine and state departments of health may follow. In my opinion it holds great promise of success because it provides means whereby every agency and every individual concerned may receive exactly what he needs and most desires through the opportunity of receiving or providing invaluable service. To the mining community it provides a clinic service so vital to our program of hospitalization. It insures interest and participation of all elements associated with medicine in its many ramifications. To the medical profession on the national and state levels it affords an ideal means of providing high-grade medical service at reasonable cost to a large segment of the population that heretofore has not been reached. It offers a graphic demonstration of the service that organized medicine is able to provide within its present framework. To public health and preventive medicine it provides the means for extending services to areas where the prevention of disease and the saving of life will be the greatest.

The Foundation's effort has served to curb costly mistakes, to plan wisely the material facilities to fit long-range needs, to develop the type of service best suited to each community's health requirements and economic resources, to teach the people and the medical profession to work together with dedication toward alleviation of suffering and long-range improvement in health of all the people in each community. This, then, is the direction of a program "based on the acceptance of the fundamental philosophy that organized medicine can 49

SUMMARY

and should assume an active role in the medical affairs of local communities and shall stand in a position to materially assist and insure the provision of good medical care to the people of the State of Tennessee."

50

APPENDIX

A

Charter of Incorporation of the Tennessee Medical Foundation STATE O F TENNESSEE C H A R T E R OF INCORPORATION BE

IT KNOWN,

That RALPH H . MONGER, A . M . PATTERSON,

E R N E S T KELLY, F . L . ROBERTS, JOHN B . YOUMANS, a n d DAUGH

W.

are hereby constituted a body politic and corporate, by the name of and style of TENNESSEE MEDICAL FOUNDATION for the purpose of: This Foundation is organized and operated exclusively for scientific purposes. Its activities shall be confined to the extension of medical knowledge, the advancement of medical science, the elevation of the standard of medical education, and the prevention and cure of disease. No part of the activities of the Foundation shall be. the carrying on of propaganda, or otherwise attempting to influence legislation, and no part of the net earnings of the Foundation shall enure to the benefit of any private share holder or individual. The general powers of said corporation shall be: (1) To sue and be sued by the corporate name. (2) To have and use a common seal, which it may alter at pleasure; if no common seal, then the signature of the name of the corporation, by any duly authorized officer, shall be legal and binding. (3) Any corporation chartered under the laws of Tennessee for religious, charitable, educational, missionary, or other eleemosynary purposes, and not for profit, shall have the power to receive property, real, personal or mixed, by purchase, gift, devise, or bequest, sell the same and apply the proceeds toward the promotion of the objects for which it is created, or hold any such property and apply the income and profits towards such objects. (4) Any corporation heretofore chartered for any of the foregoing purposes, desiring to avail itself of these powers, shall submit the question SMITH

51

APPENDIX A to its directors or trustees at any regular meeting, or special meeting, called for the purpose, or to any regular or special meeting of its executive committee, and if a majority of said directors, trustees, or executive committee vote in favor of applying for the amendment, it may then proceed in usual course to file an amendment to its charter. ( 5 ) T o establish by-laws, and make all rules and regulations not inconsistent with the laws and constitution, deemed expedient for the management of corporate affairs. ( 6 ) T o appoint such subordinate officers and agents, in addition to a president and secretary, or treasurer, as the business of the corporation may require. ( 7 ) To designate the name of the office, and fix the compensation of the officer. ( 8 ) To borrow money to be used in payment of property bought by it, and for erecting buildings, making improvements, and for other purposes germane to the objects of its creation, and secure the repayment of the money thus borrowed by mortgage, pledge, or deed of trust, upon such property, real, personal, or mixed, as may be owned by it; and it may, in like manner, secure by mortgage, pledge, or deed of trust, any existing indebtedness which it may have lawfully contracted. The said five or more corporators shall, within a convenient time after the registration of this charter, elect from their number a president, secretary, and treasurer, or the last two officers may be combined into one, said officers and the other corporators to constitute the first board of directors. Any corporation not for profit may increase its directors or trustees to a number not more than one hundred, by due and proper amendment to its by-laws, unless otherwise specifically provided. In all elections each member to be entitled to one vote, either in person or by proxy, and the result to be determined by a majority of the votes cast. Due notice of any election must be given by advertisement in a newspaper, personal notice to the members, or a day stated in the minutes of the board one month preceding the election. The term of officers may be fixed by the by-laws, the said term not, however, to exceed three years. All officers hold office until their successors are duly elected and qualified. The general welfare of society, not individual profit, is the object for which this charter is granted, and the members are not stockholders in the legal sense of the term, and no dividends or profits shall be divided among the members. The board of directors shall keep a record of all their proceedings, which shall be at all times subject to the inspection of any member. The corporation may establish branches in any other county in the state.

52

CHARTER

OF

INCORPORATION

The members may, at any time, voluntarily dissolve the corporation, by a conveyance of its assets and property to any other corporation holding a charter from the state for purposes not for individual profit, first providing for corporate debts. A violation of any of the provisions of the charter shall subject the corporation to dissolution at the instance of the state. The charter is subject to modification and amendment; and in case said modification or amendment is not accepted, corporate business is to cease, and the assets and property, after payment of debts, are to be conveyed, as aforesaid, to some other corporation holding a charter for purposes not connected with individual profit. Acquiescence in any modification, thus declared, shall be determined in a meeting of the members especially called for that purpose, and only those voting in favor of the modification shall thereafter compose the corporation. The means, assets, income or other property of the corporation shall not be employed, directly or indirectly, for any other purpose whatever than to accomplish the legitimate objects of its creation, and by no implication shall it engage in any kind of trading operation, nor hold any more real estate than is necessary for its legitimate purposes. Expulsion shall be the only remedy for the non-payment of dues by the members, and there shall be no individual liability against the members for corporate debts, but the entire corporate property shall be liable for the claims of creditors. We, the undersigned, the incorporators above mentioned, hereby apply to the State of Tennessee for a charter of incorporation for the purposes declared in the foregoing instrument. Witness our hands, this the 10th day of July, 1952. (Signed)

RALPH H . MONGER A . M . PATTERSON ERNEST KELLY F . L . ROBERTS JOHN B. YOUMANS DAUGH W . S M I T H

53

APPENDIX

Β

Form Used in the Clear Fork (Prüden) Valley Survey

FAMILY SURVEY

AREA Date

COMMUNITY Members of Family Last Name First

Age (yrs.)

Sex Μ F

Highest Present Grade Occupation School & Location

Days Worked Physical L a s t Mo. Handicaps

1. 2. 3. 4. 5. 6.

7. 8. 9. 10.

HOUSING

(Company

Own rent

(Individual.

How long in the Valley? off?

.

.

Rent per mo.

.

How long lived in present house?

House on all-weather road: yes - no.

House painted: recently - old - never.

If no, how far

Approximate floor space:

χ . State of repair: good - fair - poor. Underpinning: good - poor - none. (ft.) (ft.) Number of rooms: . Heated by: electricity - stove - grates - fireplace: other Windows: glass - shutters - none.

Screens: yes - no.

HOME CONVENIENCES Lighted: electricity - kerosene - lamps - other Do you have: radio ff5a?{eryCset - washing machine Other electric equipment

54

i g e n e r ^ o r - e l e c t r i c refrigerator

Daily p a p e r : y e s - no; weekly p a p e r : yes - no; m a g a z i n e s Automobile - t r u c k - j e e p . Kind and No. of L i v e s t o c k s : G a r d e n : y e s - no.

O t h e r m o d e s of t r a v e l ( No. of ( chickens

Q t s . of h o m e canned food on s h e l v e s

Chief v e g e t a b l e s grown:

If f a r m i n g : a c r e s in f a r m

: chief c r o p s _

Own - r e n t - u s e under p e r m i t - o t h e r SANITATION (Indoor: s e p t i c tank - p i t s - open ditch - c r e e k T o i l e t s : (Outdoor: s a n i t a r y - u n s a n i t a r y - none

Bath: y e s - no.

G a r b a g e d i s p o s a l : b u r i e d - fed to hogs - c a r r i e d off - t h r o w n out - c r e e k . (enclosed . (enclosed ; cistern Water supply: in house - outside h y d r a n t - well (open (open _(enclosed spring If w a t e r c a r r i e d , how f a r ? (open GENERAL HEALTH STATUS

( L a s t 12 months)

Any m e m b e r s of f a m i l y had: typhoid - TB - c a n c e r - d i p h t h e r i a - a r t h r i t i s other diseases or serious illnesses

- a chest x - r a y -

s h o t s f o r : d i p h t h e r i a - typhoid - s m a l l pox - whopping cough - o t h e r T o t a l days in h o s p i t a l a dentist

.

No. v i s i t s to o r f r o m a d o c t o r

P r e s e n t medical needs:

P r e s e n t dental n e e d s : DEATHS IN FAMILY ( L a s t 5 y e a r s ) Name

Relation

Y e a r of Death

Age

C a u s e of Death

1. 2. 3. 4.

COMMENTS

55

APPENDIX

C

The Clear Fork (Prüden) Valley Survey Findings A summary of information compiled in June, 1954 by Clifford Seeber, former Field Secretary, Tennessee Medical Foundation. Age Distribution. Clear Fork has a larger number of young people (under 17) and a smaller number of people in the productive ages (17-44) than the state averages for these groups. An excess of males over females in the latter category is the state-wide rural pattern for this age group. However in Pruden Valley the "17-44" age group, which includes most of the productive women and employable men, shows an excess of females over males, which may have been the result of emigration of men for employment and for service in the armed forces. Both the "45-59" and "60 years and over" categories have an excess of males over females, indicating either a rather high mortality rate for females, or an emigration of women because of limited job opportunities in the area. Size of Family. The average family of the Clear Fork area consists of 4.8 persons. This is higher than the averages, according to the 1950 census, of 4.3 for Campbell County, 4.3 for Claiborne County, and 3.7 for the State of Tennessee. Educational Level. The median number of years of school completed by persons 25 years of age and older in the Clear Fork area is about 5.7, almost 3 years less than the median for the state, 8.4 in 1950. Employment. The economy of the area rests almost entirely upon mining: 40 per cent of the heads of households reported mining as their occupation. In the last two years both the number of men employed in mining, and the number of days of work per week have

57

APPENDIX C decreased sharply. Nearly 20 per cent of the heads of households reported that they were unemployed during the period f r o m November, 1953, to March, 1954. Six coal companies, which in 1950 reported 2,200 employees, had fewer than 700 employees in 1954. In the month preceding the interview, about 41 per cent of the heads of households had had no employment and only about 20 per cent had worked 20 days or more. The average number of days worked by heads of households was only 7.4 per month. Farming plays only a minor role in the economy of the area. Although 95 families reported that they did some farming, only 14 listed it as their occupation. Cultivation of small tracts of land on a part-time basis is the usual agricultural pattern of the area. There are no manufacturing establishments, and very little gainful employment is available to women. Housing. Substandard housing appears to exist throughout the area. Over three-fourths of the houses are of frame (weatherboard) or boxed (plank) construction, and 310 houses have never been painted. About 70 per cent of the families rent; consequently little is spent on repairs. The coal companies, from whom most of the non-owners rent, spend a minimum on repairs and upkeep, particularly when work is slack. The low average rent of $8.30 per month is indicative of the poor quality of housing. In 1950 the median monthly rent in Claiborne County was $10.87; in Campbell County, $12.15; and in the state as a whole, $24.13 per month. Over half of the families reported that they had lived in their present houses for 5 or more years, and over three-fourths had lived in the area for 20 or more years. Only 84 families live in houses equipped with bathrooms; 123 families have indoor toilet facilities; 624 families have outdoor toilets, of which 66 per cent were reported as unsanitary; and 54 families have no toilet facilities. Coal mining companies provide approximately 45 per cent of the families with water in the house or at a nearby hydrant. The rest of the families obtain water from wells, cisterns, and springs. About 121 families have to carry water 500 feet or more, the equivalent of a city block. Fewer than 2 per cent of the houses have central heating systems, and fewer than 1 per cent are heated by electricity, but more than three-fourths are lighted by electricity. Nearly 89 per cent of the families have radios and about 70 per cent have some type of washing machine. Slightly more than half have mechanical refrigerators. Garbage Disposal. Five families bury their garbage; 140 carry it

58

SURVEY

FINDINGS

away; and 656 families feed it to animals, throw it out, or dump it in the creek. Newspapers and Periodicals. A total of 346 families said they subscribed to a daily newspaper, 148 a weekly newspaper; and only 183 take any type of magazine. Transportation. Of the 801 families surveyed, 370 had no private mode of transportation. The remaining 431 families reported a total of 306 automobiles, 113 trucks, 39 horses and mules, and 18 jeeps used in transportation. Fewer than two-thirds of all families live on allweather roads. Morbidity. For the 12-month period preceding the interview the following diseases were reported by families to the interviewers: Diseases

Arthritis Tuberculosis Heart trouble Pneumonia and Influenza Cancer Diphtheria Typhoid Diabetes

No. of

Patients

89 27 22 18 13 10 9 2

Two-thirds of the families reported that in the preceding 12 months no member had been in a hospital; one-third that no member had visited a doctor within that period; and three-fourths that no visits had been made to their homes by doctors. Almost two-thirds reported no visits to a dentist within the preceding year. About 23 per cent of the deaths during the preceding five years were still-births. There was an average of 6 still-births a year during that period, or 1 per 645 persons per year. In 1953 there was 1 stillbirth per 2,200 people in the state. "Heart disease" and "strokes" accounted for about 35 per cent of the total causes of death. Cancer accounted for about 10 per cent of the total.

59

APPENDIX

D

The Food Practices of School Children in Clear Fork (Pruden) Valley By Jana W. Jones and Frances N. Shoun, Nutrition Consultants, Tennessee Department of Public Health. The nutrition study in 1954 was included as a part of the total survey of health facilities and services in the Clear Fork Valley conducted by the Tennessee Medical Foundation. Portions of Campbell and Claiborne Counties in Tennessee and Bell County in Kentucky were included in the area. Two nutrition consultants f r o m the Tennessee Department of Public Health conducted the nutrition survey in Tennessee, and two nurses from the Bell County Health Department in Kentucky conducted the study in Fonde School. There were thirteen elementary schools and one school including grades one through twelve. The teaching staffs ranged in size from one to five. Only two of the schools had school lunch programs. One had a type A lunch, including milk; the other, a mission school, served a type Β lunch, without milk. In general the sanitation facilities in and around the schools were poor. One new school had drinking fountains, indoor toilets, and a place for a kitchen which was not yet equipped. In addition to information concerning food customs, home produced food, and between meal snacks, some information regarding number of members in the family, occupation of the father, and customary activities at school and home were recorded. Among the families of the 312 children interviewed, 155 made their livings from mining. Seventy of the fathers were out of work, ill, or disabled; 38 had found work elsewhere; 7 found employment in lumbering; 6 were in retail trade; 7 had no other occupations; 14 were deceased. Information on six others was not secured. Data presented in this report were obtained on the school days, 61

APPENDIX D including every week day except Saturday, during the last two weeks in February, 1954. Individual dietary interviews were held with 312 children in grades four through six. These grades were chosen because it was felt that children in this age range give more accurate pictures of food habits and are less likely to be influenced by a knowledge of nutrition than older children and that they recall more accurately than younger children. Equal numbers of boys and girls were included in the study; ages ranged from 8 to 15 years. Cooperation of pupils and teachers was excellent. Children were asked to recall the food items eaten over the last 24-hour period, including any between-meal eating, and the frequency with which food extras, such as candy, bottled beverages, and ice cream were consumed. Children were not prepared for the interviews ahead of time and no comments of approval or disapproval were made by the interviewers. The two food groups which appeared least often in the diets at this time of year were green vegetables and foods rich in vitamin C. Only 97 children out of 312 (31 per cent) had one serving of green or yellow vegetables during this period. Ninety-four children (30 per cent) had one serving of food rich in vitamin C. The ratio would have been lower had it not been for the cole slaw that was included in the school lunch menu. A few children had oranges between meals, but there were few reports of fruit juice for breakfast. Little variety was reported in the green vegetable group; canned green beans and English peas seemed to be most frequently eaten. Other vegetables and fruits, chiefly apples, canned peaches, bananas, and onions, were included in 49 per cent of the diets. Potatoes were included one or more times a day in diets reported by 226 children (72 per cent). Cheese apparently was seldom used in either family meal patterns or between meals. In the three schools where ice cream was sold, it was reported more frequently as an item in the diet. This report would indicate that consumption of cheese and milk could be encouraged in school lunches and in meals at home. More than half (61 per cent) of the children ate some type of lean meat; bologna and luncheon-type meats were frequently listed. The protein most frequently listed was dried beans, reported by 209 children (67 per cent). Twelve children had no eggs, milk, or lean meat. Contrary to the popular belief that children eat bread whether or not other foods are eaten, some of these children had too little bread; 47 62

FOOD

PRACTICES

had fewer than five servings of bread per day, the amount usually recommended for children in this age group. Table fats, such as butter or margarine, were reported by less than one-half the group (47 per cent). It is difficult to get children to report accurately on this item. Nineteen children missed one or two meals on the day reported. Some of the meals reported were inadequate in variety and in quantity. Of the children interviewed, about half (148) ate lunch at home; 53 carried packed lunches; 41 ate at a store or lunch counter; only 65 ate lunch at school. Typical lunches eaten at home included two bologna sandwiches, a banana, and a cola drink; or boiled pinto beans, fried potatoes, cornbread, and milk. Lunch at a store frequently consisted of a candy bar, cola drink, and a package of potato chips. An example of a packed lunch was two boiled ham sandwiches, a packaged cake, and a cola drink. Soft drinks were consumed more frequently than candy. There seemed to be a significant increase in the consumption of these when the father was employed, indicating that perhaps when more money was available more candy and soft drinks were consumed. It appeared, however, that as more milk was consumed there was a decrease in the consumption of soft drinks. Of the 247 children answering the question about candy, 97 (39 per cent) had candy one or two times a week; 82 had candy five or more times a week. Of 237 children reporting the number of times soft drinks were consumed, 101 had them five or more times per week. There was no way of knowing the adequacy of the home food supply. Of the 312 children interviewed, 93 reported that their families had cows; 203 had chickens, varying in number from one to twenty; 268 (85 per cent) had gardens of some kind. Reports indicated, however, that in some instances garden produce was insufficient in quantity and lacking in variety.

63

APPENDIX

Ε

Dental Findings in Six Schools of Clear Fork (Pruden) Valley During the 1953-1954 school year, the Tennessee Department of Public Health and Claiborne County School Superintendent made arrangements for a dentist to examine and do certain remedial work on the teeth of school children in the Claiborne County portion of the Clear Fork area. The following is a summary of work done under this program:

School

Children Cavities Examined Filled

Buffalo Clearfield Eagan Pruden Tackett Creek Valley Creek TOTALS

Extractions

Root Tips Removed

Oral Good

Hygiene Fair Poor

13 58

85 381

14

2

2

7

2

50

12

19 48

1

13

43 22

89

433 651

3 4

10

47

18

5

30

54

15

104

11

10

0

0

15

19

140

10

2

0

0

19

241

1,794

152

45

14

60

155

These figures indicated an urgent need for remedial dental work among school children of the Clear Fork area. Dentists attributed these poor dental conditions to excessive consumption of sweets and soft drinks, poor dental hygiene, and failure to visit dentists.

65

APPENDIX

F

Consultant Services to Rural Clinics and Hospitals The Tennessee Medical Foundation initiated a consultant program as an instrument to help meet the need for improved diagnostic and therapeutic services and to lessen the isolation of physicians practicing in rural areas. In addition, it was felt that such a service might attract physicians to these areas and increase the medical manpower where needed. Other groups that have experimented in this field saw the need for such a service for essentially the same reasons. Initially a letter was sent to each member of the Knoxville Academy of Medicine with the request that he indicate whether he would be willing to serve as a consultant. A panel of consultants was then established. Then consultant visits each month were arranged to the Clear Fork Community Clinic in Prüden Valley. Later the program was extended to the Morgan County Medical Center at Wartburg, Sequatchie County General Hospital, Scott County Hospital, Uplands Cumberland Mountain Sanatorium, LaFollette Community Hospital, and the Palmer Clinic. Originally the mechanics of rotation were handled by the Field Secretary. Later a physician was given responsibility for the operation of this phase of the Foundation's activity. The local doctors who utilize this service for their patients believe that the consultant program has these advantages: It offers better medical care for patients. It increases the prestige of the clinic and the doctor. It serves as an invaluable device for the further education of the clinic doctor. It serves as an educational program for the specialist by familiarizing him with many of the problems encountered by general practitioners in the rural areas.

67

APPENDIX

F

Some of the problems encountered in operation of the program are: Patients frequently do not keep the appointment with the specialist. This is gradually being improved through a concerted educational program carried on by the clinic doctor. Necessary instruments are not always available for the specialist to make as complete an examination as would be the case if the patient were in the specialist's own office. Laboratory facilities in some of the rural clinics are limited. Cases seen are nearly always elective. Patients requiring immediate specialty treatment must be sent on to a larger medical center where this care is available. Constant effort is being made to extend and improve the consultant program. Better medical care is available in the rural areas through the close working relations of the specialist and the general practitioner in a local setting.

68