Participants consistently named as a challenge the lack of quality and accessible health care and mental care and the many ways that this impacts their communities. It also contributes to the urban rural divide as many do not believe that access to quality medical care is enjoyed equitably across the state. The number of health care providers is simply less than in more populated areas, which struggle to attract and retain providers. The sheer distance from one’s home to a doctor’s office may be more than an hour, even two, especially for specific care like obstetrics and gynecology, cancer treatment, addiction services or even dental care.
I was an economist for 17 years. I see the problems the same in rural areas as urban areas, but the complexities – like transportation - in rural area are more severe. (Medford Dialogues)
So one example is when our local hospital was taken over by another larger one. We have to drive 20 miles. Some people 30 or 40 miles to Madras for the hospital and there is no OB unit! (Warm Springs Dialogue)
For transit, healthcare and other grants, when you have to do a cost benefit analysis, you can't compete with the cost benefit of an urban area. (Lincoln City Dialogues)
Participants across all Dialogues recognize the cost benefit of providing services in Oregon’s more populated areas, with Portland and Eugene named as cities offering the full slate of health care services, but also regional hub like Lincoln City, Medford, and eastern Oregon cities that can go to Boise, Idaho. Deschutes, Jefferson, and Crook County collaborate around health care. Still, Jefferson and Crook Counties, per a Participant see services come and disappear because they both have populations under 30,000 whereas Deschutes County is closer to 200,000 residents. It’s frustrating for all involved in these cases.
Residents beyond these regional hubs are challenged with the traveling the long distance for care. Communities with these low populations are challenged to support their residents wholly. Mental care and addiction support came up frequently.
Medford Participants in particular discussed America’s aging population and aging health care providers. “Every day, 10,000 people are turning 65 in the United States,” shared a Participant. The statistic was found in an AARP funded report, “The Aging Readiness and Competitiveness Report.” This matters not just for the number of people needing extra care, but this population consists of seniors who are also retiring and leaving the workforce. “The deficit in the service providers will be huge,” continued the Participant and the pipeline of new health care professionals have not been developed. Another added, “We have the biggest needs in the healthcare industry around caregivers. The lowest wage for the health occupations is caregivers.”
MENTAL HEALTH CARE
Participants intertwined these issues with the lack of mental health care and prevalence of addiction across Oregon. Participants shared horrifying numbers. Suicide rates are increasing in teens, veterans, and disproportionately rural populations. Over one-third of girls and women have wrestled with major mental health care issues. “Every community that I know have said that meth and alcohol are issues,” shared a Warm Springs Participant. “The mental illness issues are tougher because the complexities go deeper, faster. The potential for solutions or resolution get harder faster,” shared a Medford Participant. Mental health providers cannot keep pace with the need in rural Oregon, which a Participant described as barren wastelands in terms of access to social services. Community health care workers are a solution but there was a sentiment that funding to support enough workers is disproportionate to the need.
Similar to the above discussion about cost benefit analysis, one Participant gave the example of Oregon’s Adult Drug Court program. It is an intensive program to help adults with problems of addiction to find a better life. Funding for it though is based on the number of participants so Multnomah County has plenty of funds whereas other jurisdictions have significantly less and are challenged to fully support the program.
There's a mental health crisis nationwide and it's really a really serious in southern Oregon and we have a total lack of resources in trying to deal with it. (Medford Dialogues)
I’d like to figure out how to help people who are lost right now because they're different populations. That's where you get at the meth population. (Medford Dialogues)
In the area of health, it's mental health care and in a million different ways, including alcohol and drug issues. (Warm Springs Dialogues)
At the Portland Dialogues, a Participant named isolation as one thing preventing communities from thriving and dragging them down. This exists in both urban and rural. Isolation contributes to suicide, school shootings, mental health and behavioral challenges. They shared, “I think the root cause of a lot of degradation of communities, no matter whether they're urban or rural comes back to isolation.”
Another shared that they believe that we as a whole are not taking care of ourselves well enough. We're not learning how to manage the stress. Were we to get better at that in our community, many other things I believe would, if not resolve, improve connectedness, ability to think clearly and rationally in ways that address problems rather than respond to threats. And that is a pretty deep level thing.
Adverse Childhood Experiences
These health care issues impact whole communities. Participants discussed how teachers are burdened with handling mental health and alcohol abuse while still doing their job of teaching classes of healthy students. Students impacted by trauma and mental health issues cannot receive quality care, impeding their concentration and ability to learn, complete assignments, and stay in school.
“Adverse Childhood Experiences,” or abbreviated as “ACEs” is a term for events experienced by children (ages 0-17 years old) that are possibly traumatic and came up in about half of the small group conversations in Medford, as well as a few times in other Dialogues.
Examples of ACEs include experiencing or witnessing violence, abuse or neglect or experiences that undermine a child’s sense of safety, stability or bonding, as described on the Center for Disease Control and Prevention. A Participant described that if someone has experienced three or more ACEs then someone is exponentially more likely to have mental health issues. As one Participant described, “It’s a form of PSTD so it can be passed on from generation to generation. It's a cycle of trauma.” Another Participant called ACEs “the biology of stress.” Two Participants gave the heartbreaking statistic that one southern Oregon county has the highest suicide rate for teens. As Participants discussed, one said, “It’s looking really bleak, right?”
The stress takes a huge toll on the minds and bodies of young children. “Kids who don't have housing, they're not ready for kindergarten. Kids who don't have healthcare, they're not ready for kindergarten. Kids that go to a different caregiver every day because there's no childcare, they're not ready for kindergarten.” The system is so challenged and fraught. It creates unintentional problems, as one explained, “We offer universal K-12, but we don't universally make sure kids are ready to be successful in that experience. Something as small as when a kid gets moved from house to house, allow them to stay in their school. That would make that child's educational experience so much better.” Another reacted, “Our area is especially inundated with these problems.”
The hopelessness seems as compounded as these issues. There’s a sense that solving these issues and helping end cycles that contribute to people’s struggles is like stopping waves on a beach. Any number of people cannot make a difference.
A Participant provided one success story, describing a southern Oregon school district that has been engaging teachers and other educational providers with the Adverse Childhood Experiences study. The professionals take the ACEs test and answer questions about their family and personal experiences with the identified traumas. There's an empathy or recognition when people understand how those traumas exist within themselves. This personal illumination, finding empathy for themselves, and talking about it in the ACEs trainings, positions the professionals to better support students. The educational professionals are profoundly impacted to learn how their words have re-traumatized children. “It's really amazing to watch how that changes everybody in the room,” a Participant shared. “In this case it's happenings with parents, teachers and administrators. Everybody is doing the deep dive getting involved with community. It's a slow process because it's just happening a little bit by little bit, but…” And a Participant added, “Sometimes you have to go slow to go fast.”
HISTORICAL TRAUMA
Participants described and discussed “historical trauma,” which the U.S. Department of Health and Human Services is defined as “multigenerational trauma experienced by a specific cultural, racial or ethnic group.” That can includes genocide, slavery, forced relocation, and/or destruction of cultural practices. These wounds are can be felt across generations and, as one Participant described, are at the core of addiction and other issues. Alcohol and drugs are used to numb a pain is not always describable. Victims also use violence against themselves or others. A Medford Participant gave the example that as children of color with historical trauma age into their teens and their awareness of their world and self increases, attempted suicides and suicide rates increase.
I think of health in the broadest sense. Being from the southern part of the state, where we have a significant addiction issue, that's a result of the trauma, historical trauma and traumas coming together… It has resulted in a culture of addiction… Everybody experiences it no matter if they're addicted or not. (Medford Dialogues)
We have done surveys in the community in the past and found that one in five people forego necessary medical care because they don't think they'll be treated fairly or even approved to get the care that they need. (Warm Springs Dialogues)
Poverty and disenfranchisement perpetuate the historical trauma. Lack of transportation and financial resources to cover health care fees prevent some from getting help. Medford and Warm Springs Participants, both Native American, shared that they are using trauma-informed care to help their membership. Trauma-informed care takes into account the possibility of trauma and its pervasive nature. Some care teams may focus on childhood, historical, or both. They promote and use language and care to help patients reach recovery and not re-traumatization. Participants also referenced culturally competent health care, specifically referenced for transgender folks.
In the mainstream world, Participants described that health care practitioners do not often know to incorporate trauma-informed or culturally informed care with their patients. Worse, patients can face discrimination when seeking health care. Participants of Color shared experiences of receiving hostile tones and aggressive behaviors. It can be hard to maintain hope, dignity and appreciation for one’s self, when faced with such animosity in a setting designed to take care of you. The Participant continued, “There is a racial divide, there's not a real understanding of the social issues that would be helpful for us to move forward and heal our whole community.” One added, “We are trying to work on and heal our people, but it's a daily reminder when you go out and you see our areas where we used to be. “
On the positive side, a Participant mentioned La Clinica in Medford, which, according to their website, “strives to improve the quality of life for the diverse communities we serve by providing culturally appropriate, accessible, and affordable quality health care.”
CYCLES AND IMPACT OF TRAUMA AND ADDICTION
Participants spoke at length about the negative health impacts of housing instability, houselessness, and low-wage and/or inconsistent work and how these issues are all so intertwined. A Portland Participant shared a survey happening in their county where findings show that the most common response to people’s number one health issue is housing. The second most common reply was education. “Housing and education have health implications for our community and not connecting these dots keeps us at odds with responding to these issues,” the Participant shared. Another Medford social services worker shared, " There is stress in downward mobility. There is less security, less sleep; more stress, and sick more often. It’s where health disparities start.”
In Madras, we have a high percentage of unwed mothers giving birth. We have a high percentage of Diabetes. We have a high percentage of heart disease. Physical health is an issue. Oftentimes it's tied to a fractured family, separation, drugs, or divorce. Kids are present at school but they are not able to concentrate. Adults cannot show up consistently for work. (Warm Springs Dialogue)
The sentiment was strongest around providing more safety nets for people coming on hard times and to holistically address problems of poor health, unstable housing, low-wage work, and limited education are so intertwined. Participants wished to not just address a patient’s high blood pressure but to understand what is causing it. Communities need more and better social services and health care, as well as more opportunity in the sense of family-wage jobs. Untreated struggles with physical and mental health care impact a person for their life and it’s costly for them, their community, and Oregon. Participants that are social service professionals are worn out of inadequate solutions, “After 20 years in my job, to some extent I’ve been beaten down, not so much the lack of agreement or cooperation, but lack of resources to address some of the most important issues that face us. I’m oriented around triage, addressing the most urgent issues with whatever is available.”