Opportunities in Practice and Education in the Delta  
Michael Carter, DNSc, FAAN  
University Distinguished Professor  
The University of Tennessee Health Science Center

Adapted from a Presentation at the Annual Summit Meeting of
The Delta Health Education Partnership
New Orleans, LA  September 20-22, 2000

   
             The purpose of this paper is to discuss some of the opportunities in health care practice and education in the lower Mississippi Delta area.  This is an area like no other in the world and some background of the area is important to understand the context of the area.  This background will provide the framework better understand some of the opportunities in practice and education.

             In this paper, the lower Mississippi River Delta area is the region now known as Tennessee, Kentucky, Missouri, Arkansas and Mississippi.  All of these states derive their names from the languages of the native peoples who were here long before the Europeans, Asians, and Africans. 

             It is a land formed by the action of wind and water as well as by movements of the earth.  The Mississippi is the third largest river system in the world following the Nile and the Amazon.  All of the our soil here in the Delta is alluvial soil, silted over the millennia by the rivers and winds.  There are no stones - one must travel almost 100 miles to either the east or west of the river to find stones.  Here are found the deep, rich soils and abundant water that have supported so diverse flora and fauna as well as deep, rich cultures.

             The Delta was the home for the first peoples known as the Chickasaw, Choctaw, Osage, Quapaw, Casqui and Coshata among others.  Food was plentiful and travel was possible by the rivers.  Clearly, it was much easier to go down stream on the rivers because of the current but travel up stream was easier than attempting to move over land.  In addition to the deer, bear, turkey and many other animals that provided food and clothing, there was an abundance of fish and mollusks.  Today, the fresh water mussel of the Tennessee River is the source of all the cultured pearls in the world in that the shell is use for the blank for the oyster.  Arkansas, Missouri, Kentucky and Tennessee mussels provided the source of mother of pearl buttons that were used for years. 

             The topography of the area is similar to that of other delta areas.  It is flat and there are many swamps.  The large rivers have left a number of ox bows as they change their channel and these team with fresh water fish and turtles - all good to eat.  There are also a many snakes including all the poisonous varieties found in North America.  Insects are everywhere in great abundance and these include mosquito that carry diseases.

              Here and there are areas of high ground such as those found in Memphis where the Chickasaw people formed a large town on the bluff.  This area remained above the yearly spring flooding of the river.  The east of the river was always above water while the west side could go under at any time if there had been heavy rain fall upstream.  The Crowley’s ridge area, extending from Missouri to Mississippi, remains today as one of the great, unexplained phenomena.  However, it provided relief during periods of flooding.

             The rivers provided the best transportation.  The remaining land was wet, gummy, or covered by thick forests. Each year, the Mississippi brought a new layer of fresh soil in the spring.  The Mississippi River is a composition of several river drainage areas.  Clearly, there is the New Orleans to Minnesota Mississippi component.  In St. Louis we find the Missouri River branch that extends almost 2,000 miles to the Rocky Mountains and was the route of Louis and Clark.  The majority of the water in the Mississippi River that flows in the Lower Delta comes from neither of these, however.  It is from the Ohio and Tennessee River drainage.  These drain the Midwest portion of the United States west of the Appalachian Mountains.  South of Memphis we find the Arkansas River joining the Mississippi River.  The Arkansas begins outside of Leadville, Colorado and flows through Kansas and Oklahoma before reaching Arkansas.  Draining the Ozark mountains is the White River.  This river was subject to violent flash flooding because of the high rain fall and steep relief.

             More recently, humans have attempted to place controls on these rivers through dams and levees.  These have made human habitation and farming possible in areas not previously possible.  In the long run the rivers will win. 

             Following the settlement by the original people, came the Europeans.  Hernando DeSoto moved through the area and his name remains in several places such as towns, bridges, and counties.  The Spanish and the French were very influential in the 1600s and 1700s.  The Louisiana Purchase in the early 1800 added Louisiana, Arkansas and Missouri (as well as a great deal more land) to the United States and opened the entire area to settlement.  Today there are many French and Spanish influences that remain along with the influences of the aboriginal people. 

             There were few roads with these early people.  Travel still had to be done primarily by river.  There were vast forests including large cypress trees in the swamp areas.  This particular wood was highly valued for its resistance to rot and insects.  The entire cypress growths were harvested leaving the land available for other uses. 

             Along with the influences of the river in molding the topography was the influence of the shifting earth.  The largest earthquake ever recorded in North America was the New Madrid earthquake in the 1800s.  This seismic action changed the course of the Mississippi River, created new lakes, and destroyed many towns along the river.  The fault line tends to follow the river and because the soil is all alluvial, there is the potential of massive destruction when the next big one hits.

             Water is everywhere but little of this water was fit to drink.  Yellow fever and malaria abounded in this area until the 1940’s.  The city of Memphis is named for the ancient city of Memphis Egypt the home of Ramse the Great. (The word, Memphis is the Americanized word for that city and means good abode) Memphis at one time gave up its charter as a city because of the massive deaths due to Yellow Fever.  Memphis was able to discover a large aquifer that even today provides large quantities of clean, pure water.  This allowed for rapid population growth.  New Orleans has yet to find such a supply of water, but this has not blunted its growth over the years and the great influx of people from throughout the world.

             The Mid South is an area of farming.  Local television in carries many advertisements for farming products.  In the 1700s and 1800s large plantations were developed that relied on cotton for their cash crop.  The only way that cotton would be profitable was by the use of slavery.  Slavery grew quickly following the advent of the cotton gin.  Cotton was a labor intense crop.  Planted in the late spring when the soil became hot, cotton required constant weeding with a hoe, known as chopping cotton, and then had to be picked by hand.  A small group of very wealthy land- owners held title to massive plantations that exploited the labors of the tens of thousands of slaves.  These plantation owners, or planters, built massive homes throughout the area, many of which still exist today.

             Not much changed following the Civil War.  Moving from slavery to sharecropping did little to change the life of many rural African Americans.  Sharecropping usually meant a cycle of endless debt.  Half of what the sharecropper grew belonged to the owner outright. To purchase supplies or rent a “Shotgun” shack (named because a blast fired through the front door went straight out the back door), the sharecropper borrowed from the plantation owner in the spring.  This loan was called “furnish”.  Payment was due at “settle” when the fall crop came in.  Any money the sharecropper made came from what was left over.  Often he got nothing or owed money.  The plantation owner kept the books and keeps the figures.  If you disagree, you move, you go to another plantation.  This meant that the worker was forever indebted to the planter.

             There were exceptions to this form of servitude such as in the small town of Henning, Tennessee where former slave families opened small businesses and shared the stories of their history.  Alex Hailey later shared these stories that he learned on the front porch of his grandparents home in his story of Roots.

             Many changes came to the Mid South in the 20th century.  Between 1915 and 1970 more than five million African Americans left from every field and corner of the Mid South, most going to the nation’s booming cities.  Often they stopped in larger towns like Memphis where part of the family might be left while the able bodied looked for work further north in St. Louis, Chicago and Detroit. 

             Why did this massive exodus occur?  The primary reason was the mechanization of the farm.  In the early days one worker was required for each acre of land to bring in a crop of cotton.  These workers chopped and picked the crop.  There is an old saying that you have not back when you pick cotton.  Mules and people were replaced by machine.  Each worker could bring in 100 to 500 acres of crop and now the crops were more diversified.

             The revolution in Russia at the turn of the century brought large numbers of Jewish emigrants to the Mid South cities to join the small Jewish population already here.  This group joined merchants along Beal Street and the Pinch District in Memphis as well as in the towns of Vicksburg, New Orleans, Helena, Little Rock, McGehee, and Pine Bluff Arkansas and most towns along the rivers of the area.  Many small towns had their own synagogues.  Today, the Baron Hursh Congregation in Memphis is one of the largest orthodox communities in the US.  Most of the smaller towns, however, have lost their Jewish community and most synagogues have been deactivated.

             During World War II Japanese American families were forcibly moved into internment camps and one of these, Rhor, is on the west bank of the Mississippi River in southern Arkansas.  Following the war, many of these people remained in the area adding to the richness of the area. 

             Following the fall of Viet Nam, many Southeast Asian families were moved to Arkansas and from there spread into the Delta.  More recently other Southeast Asian families have been assisted in moving to the area by Catholic Charities and other groups. Many continue their Buddhist faith.  Most recently, there has been an influx of Spanish speaking  people from Mexico and Central and South America to work in the many jobs available.  These are not the migrant workers of other areas but individuals willing to take jobs that others are not willing to do such as in the chicken industry.

             Also, the gaming industry of Mississippi has brought in large numbers of workers from Africa to provide the labor needed.  Tunica County Mississippi, 20 miles south of Memphis, is the third largest gambling location in America.  At one time this was one of the poorest counties in America with less than one half of the people having running water and indoor plumbing.  Today, there is no longer local property tax because of the riches brought by gaming.

             Today we find an interesting mixture in the Delta.  The Delta is the home of large, international companies such as Federal Express and The Promus Corporation (that grew from Holiday Inns) and a number of other important corporations employing a large number of people in fairly low skilled jobs.  Health care is a major business in the Memphis area.  The largest and third largest hospitals in the US are located here.  Yet the health statistics of the majority of the population in the Delta are some of the worse in the nation often exceeding many countries in the developing world.  We continue to have census tracks where the infant mortality is greater than 50 per 1000.  One can live in sight of a major medical center where wonders of organ transplantation take place each day but not be able to access basic preventive care to recognize and treat hypertension.

             Many of the differences that we see in health care are reminiscent of the long time differences growing out of slavery.  Long held views of the population that there were expected differences between black and white have lead to tensions that could not be contained.  These tensions came to a tragic explosion on the fateful evening in April of 1968 here in Memphis at the Lorain Hotel with the murder of Dr. King.  The recovery from this event has been long and will likely never be complete. This tragic event continues to frame many of the political, economic, cultural and religious issues today in the Delta.

             The Delta is also the home of some of the largest churches in the nation.  Most of these are based on conservative or fundamental Christianity.  The Delta is described as the “Buckle of the Bible Belt”.  Yet, Dr. King pointed out that the hour of 11:00 a.m. to 12 noon on Sunday as the most segregated hour in America.  That is surely the case today in the Delta for few of the thousands of churches here have a mixed congregation.  One area of controversy relates to Christianity.  While slaves were not allowed to read or write, they were allowed and encouraged to convert to Christianity.

             Christianity promised a much better life in the next life and the old spirituals call on the believer to struggle on for a better eternity.   Religion was most often communicated by the word than by the book because so many people in our area could not read.  Prior to the Civil War it was a crime to teach slaves to read or write.  Preachers of the many small churches tend to be called rather than trained because it is the spirit that moves our people.

             We remain an economy tied to agriculture.  Row crops of cotton, rice, soybeans, wheat, milo, corn and others are farmed year round.  Our language, food, music and religions are tied to the earth and the struggle to bring in the crop.  A specific form of music, the Blues, was born of this region and best characterized by Bourbon Street and by Beal Street, the home of the Blues.  This term goes back to 18th century England where the “blue devils” was slang for melancholia.  It was the sorrow common among black people after the Civil War that led to a raw new music depicting work, love, poverty, and the hardships freedmen faced in a world barely removed from slavery.

             The notable people of the Delta include Tina Turner, Johnny Cash, Isaac Hayes, BB King, and of course, The King - Elvis Presley.  Clearly it is spirit that has moved these people and that spirit has been born from all that is the Delta.

            How then do we form an understanding of these interplays of wealth amid poverty; vast supplies of water but little potable; deep and rich soils but always being moved toward the gulf; former slave and former master; state of the science health care along side third world health statistics?  This is the Delta and it is here that we have opportunities like no others in the nation.  As we understand these unique interplays we can then form our solutions for some very vexing problems in health care practice and education.

The United States has serious problems in the way the health system is organized and financed.  These problems mean that our health care system is continuing to undergo dramatic and sometimes, chaotic changes.  The US already spends far more per capita on health care than any industrialized country such as Canada, Germany, France, Sweden, Japan and the United Kingdom.   This excess spending varies from 50 percent more per capita than Canada to 175 percent more per capita than the United Kingdom.  Improving the US health care system will not likely come about by increased spending but rather by developing different ways in which to organize the care delivery system and different ways in which to pay for services.

            This is particularly true for the Delta.  Substantial more money for health care will not likely occur in our states.  Our states are poor and  have limited ability to substantially change their funding bases.  Instead, what we are more likely to see is continued tinkering with the current system, responding to even greater calls for reduced or at least flat state expenditures, and further attempts to limit payments from private and government health insurance systems. 

            If I were to sum our major problems in our system of health care in our region I would say that it is more costly per person, is less accessible, focuses on intensive levels, and has poorer outcomes than the systems of other industrialized countries.  Yet, it is a reflection of the rest of the nation.

            So what can be done about this and what opportunities exist in practice and education for us?  Well, as you might guess, I have some ideas here. 

            The first potential solution is to create health policy that assures universal access to preventive care especially for women, children and other at risk populations. This will have to be at the federal level because the states have shown that they are not able to do this.  We can see Arkansas and Texas as examples of what not to do in Medicaid. 

            The Annie E. Casey Foundation reported that the states of Louisiana, Mississippi, Arkansas, and Tennessee were ranked number 50, 49, 48, and 46 as having the worst measures of child well-being.  While the other states can continue their chant, Thank God for Mississippi, Louisiana can’t do that this time.  Nelson Mandela told us “There is no keener revelation of a society’s soul than the way in which it treats its children”. Clearly, his message is here for us.

            There is still about 17 percent of the Delta population without insurance and they can seldom afford the out of pocket expenses of immunizations, well child examinations, and screening procedures that have been traditionally performed in the private physician's office.  The uninsured population figure does not fully cover the substantial additional population that is under insured particularly by health care plans that do not pay for preventive services. 

            Advanced practice nurses and Physician Assistants have shown that they can increase access to preventive services at an affordable price and especially to populations not previously covered by private insurance.  Several states have requested Medicaid waivers from the Health Care Financing Authority to expand services to additional populations.  The case example of TennCare, the State of Tennessee Medicaid waiver program, shows that working poor and people who cannot purchase insurance because of preexisting conditions can be included in preventive services.  The TennCare program mandates by state regulation that nurse practitioners and nurse midwives be allowed to participate as primary care case managers.  This role is the gatekeeper to the rest of the system.  Physician Assistants, while not listed as primary care case managers, can participate in the program as well.

            Educational programs in the region must use their covenant with the population to demand the changes in health policy to make coverage of our population happen.  Except for our Midwifery partners, all the rest of us in the DHEP project are state sponsored educational programs.  We have a special relationship with our states and must fully exploit this relationship to demand needed changes.  We are the experts and this is certainly no time to be shy.

            One of the most wonderful thing about our Delta region is that we can affect health policy in important ways.  Our state legislatures can and do listen to us – sometimes not the first or second time, but elections here are very local and our representatives can be influenced.  Our primary care providers are close to the people of the area and this means that they are close to the legislative representatives in ways not seen in more populated areas.  We can and often do show the problems that can be fixed by state policy.

            A second potential solution to the current health care problems seen in our region is to increase access to primary care especially to under served populations.  These populations include children, women, rural and inner city residents, and minorities.  Clearly, changing the funding for primary care is important to increase access but also important is expanding the role of advanced practice nurses and physician assistants to deliver this care.  What will be required in the future is to remove the barriers and restrictions on practice and to construct incentives within the funding stream to support family and community based practice.  I seem to be back to the policy issue again.  Some of our states still have rules and regulations that restrict our full scope practice in ways that are harmful to primary care provision.  We must continue to form a united front to have these restrictions removed.  Our strength comes from our united activities.  No where else in our area are such diverse groups working for such a common purpose – to bring primary health care to people most in need.  Our work is not done and in some of our states we have issues that can seem overwhelming.  Through collective action, however, this can be overcome. This reminds me of my earlier work in the 1960s.  However, collective action worked then and continues to work today and as a collective of education programs and practitioners we can be even more successful.

            A third potential solution is to accelerate the practice of self-care and self- management of common acute and chronic illnesses by patients.  The health care system must move from paternalism that is characterized by high legitimate authority for the professional to a shared authority for health decisions between the patient and the professional.  Substantial decrease in demand for care and increase in quality is seen when people are given the information needed to manage their own health problems and the support from professionals for this management.  This shift in the focus of control for health decisions is not easily accomplished particularly in a litigious society.  New technologies, however, can assist with this shift and the schools in the area can lead the way.  We can help people recapture their right and authority for their own health.  Their approaches will be culturally specific and will have the highest quality outcomes in the long run.

            The development of the information superhighway for the first time allows people access to information with little regard for the location of the user vis-a-vis the source.  The development of on-line, computer assisted communications among patients, medical databases and health care providers can replace a substantial amount of the care that is now delivered in person (or in the case of the Delta, is not provided because of restrictions on the practices of advanced practice nurses and physician assistants.   Our students and faculty, particularly those in rural locations, are quickly learning to make use of the Internet for their own information needs.  It is a very short step for these providers to move the patients they serve into this information and communication stream.  Patients can make better self-care decisions once they have the needed information. Our DHEP is having one of the most critical successes by bringing innovative approaches to web based learning to the Delta.  This approach to what will be life long learning will serve the region for the decades ahead.

            The fourth potential solution is controversial.   This solution is to change the priorities of our spending.  No novice at controversy, Richard Lamm has argued that the US spends far too much on the elderly and too little on the rest of the population.  Older Americans make up less than 13 percent of the population but consume over 60 percent of the federal social spending.  Often these expenditures have no positive outcome in improving the quality of life. Our area is one with high elderly population that has not been well served by our health care system.

            Advanced practice nurses and physician assistants practicing within the context of family and community understanding can assist older Americans in our region to make better and less costly choices in health care.  The last year of life for older Americans is often very costly and this is even more true in our region than the rest of the nation.  The medical costs during this time of life often represent overly intensive care for terminal illnesses.  Just when a person is going to die is not always easy to predict, but certain diagnoses increase the likelihood.  Across the nation over 70 percent of elderly request no life-sustaining treatment when they are dying and 89 percent desire living wills, but only 9 percent have completed living wills or other advanced directives.  While specific data for the Delta are not available, I suspect that even fewer have advanced directives as so many do not read and so few have been well treated by our health care system.  Changing a substantial amount of health care expenditure need not be as draconian as the suggestions of Lamm but could be as simple as assisting older people in our area understand their options for end of life care and helping them select their desired choices.

            These are not new or particularly innovative ideas that I have proposed.  What is new is that we as clinicians and educators in the Delta must create better understanding of the forces that create our daily lives.  From this understanding, we can then help form solutions that fit our people and their lives.  For it is only, when solutions fit the unique nature of the problem as lived by our people that we can then hope to see progress.

We have the chance to make choices in our practices and our educational programs.  We can choose to move with the status quo or we can take another path – one that will be different in many ways from the paths taken in the past.   Robert Frost's (1916) poem, The Road Not Taken can serve as our guide.  He says: 

            I shall be telling this with a sigh

            Somewhere ages and ages hence;

            Two roads diverged in a wood, and I --

            I took the one less traveled by,

            And that has made all the difference.

To not take a different path is to follow the warning of C. S. Lewis in his book, The Screwtape Letters. 

The safest road to Hell is the gradual one--the gentle slope, soft underfoot, without sudden turnings, without milestones, without signposts.

I think we will not take the gradual road but to diverge and take the road less traveled – and that shall make all the difference for our students, our patients, and our communities.  They expect no less from us nor should we expect any less from ourselves.