Mr. and Mrs. Evans are an African American couple who retired from the school system last year. Both are 65 years of age and reside on 20 acres of land in a large rural community approximately 5 miles from a Superfund site and 20 miles from two chemical plants.
Their household consists of their two daughters, Anna, aged 40 years, and Dorothy, aged 42 years; their grandchildren, aged 25, 20, 19, and 18; and their 2- year-old great-grandson. Anna and Dorothy and their children all attended the university. Mr. Evans’s mother and three of his nieces and nephews live next door.
Mr. Evans’s mother has brothers, sisters, other sons and daughters, grandchildren, and great-grandchildren who live across the road on 10 acres of land. Other immediate and extended family live on the 80 acres adjacent to Mr. Evans’s mother.
All members of the Evans family own the land on which they live. Mrs. Evans has siblings and extended family living on 70 acres of land adjacent to Mr. Evans’s family, who live across the road. Mr. and Mrs. Evans also have family living in Chicago, Detroit, New York, San Francisco, and Houston.
Once a year, the families come together for a reunion. Every other month, local family members come together for a social hour. The family believes in strict discipline with lots of love. It is common to see adult members of the family discipline the younger children, regardless of who the parents are.
Mr. Evans has hypertension and diabetes. Mrs. Evans has hypertension. Both are on medication. Their daughter Dorothy is bipolar and is on medication. Within the last 5 years, Mr. Evans has had several relatives diagnosed with lung cancer and colon cancer.
One of his maternal uncles died last year from lung cancer. Mrs. Evans has indicated on her driver’s license that she is an organ donor. Sources of income for Mr. and Mrs. Evans are their pensions from the school system and Social Security. Dorothy receives SSI because she is unable to work any longer.
Mr. Evans and his brothers must assume responsibility for their mother’s medical bills and medication. Although she has Medicare parts A and B, many of her expenses are not covered. Mr. and Mrs. Evans, all members of their household, and all other extended family in the community attend a large Baptist church in the city.
Several family members, including Mr. and Mrs. Evans, sing in the choir, are members of the usher board, teach Bible classes, and do community ministry.
Appalachian Case Study #1
William Kapp, aged 55 years, and his wife, Gloria, aged 37, have recently moved from an isolated rural area of northern Appalachia to Denver, Colorado, because of Gloria’s failing health. Mrs. Kapp has had pulmonary tuberculosis for several years. They decided to move to New Mexico because they heard that the climate was better for Mrs. Kapp’s pulmonary condition.
For an unknown reason, they stayed in Denver, where William obtained employment making machine parts. The Kapp’s oldest daughter, Ruth, aged 20, Ruth’s husband, Roy, aged 24, and their daughter, Rebecca, aged 17 months, moved with them so Ruth could help care for her ailing mother.
After 2 months, Roy returned to northern Appalachia because he was unable to find work in Denver. Ruth is 3 months’ pregnant. Because Mrs. Kapp has been feeling “more poorly” in the last few days, she has come to the clinic and is accompanied by her husband, William, her daughter Ruth, and her granddaughter, Rebecca.
On admission, Gloria is expectorating greenish sputum, which her husband estimates to be about a teacupful each day. Gloria is 5 ft 5 in. tall and weighs 92 pounds. Her temperature is 101.4°F, her pulse is regular at 96 beats per minute, and her respiration are 30 per minute and laboured.
Her skin is dry and scaly with poor turgor. While the physician is examining Mrs. Kapp, the nurse is taking additional historical and demographic data from Mr. Kapp and Ruth. The nurse finds that Ruth has had no prenatal care and that her first child, Rebecca, was delivered at home with the assistance of a neighbour.
Rebecca is pale and suffers from frequent bouts of diarrhoea and colicky symptoms. Mr. Kapp declines to offer information regarding his health status and states that he takes care of himself. This is the first time Mrs. Kapp has seen a health-care provider since their relocation.
Mr. Kapp has been treating his wife with a blood tonic he makes from soaking nails in water; a poultice he makes from turpentine and lard, which he applies to her chest each morning; and a cough medicine he makes from rock candy, whiskey, and honey, which he has her take a tablespoon of four times a day.
He feels this has been more beneficial than the prescription medication given to them before they relocated. The child, Rebecca, has been taking a cup of ginseng tea for her colicky symptoms each night and a cup of red bark tea each morning for her diarrhoea. Ruth’s only complaint is the “sick headache” she gets three to four times a week. She takes ginseng tea and Epsom salts for the headache.
Mrs. Kapp is discharged with prescriptions for isoniazid, rifampin, and an antibiotic and with instructions to return in 1 week for follow-up based on the results of blood tests, chest radio-graph, and sputum cultures.
She is also told to return to the clinic or emergency department if her symptoms worsen before then. The nurse gives Ruth directions for making appointments with the prenatal clinic for herself and the paediatric well-child clinic for Rebecca.