By Laura Ungar

The Courier-Journal

SANDY HOOK, Ky. — Diabetes is slowly ravaging Alisha Blankenbeckler's body — stealing her eyesight, impairing her kidneys and damaging her nerves so severely she can barely walk across a parking lot without help. And she's only 48.

"I try to stay upbeat no matter how bad I feel," she says, mostly so she can keep caring for a husband with dangerously high blood pressure. "It's difficult, though. Dying is something I think about every day."

The couple's travails are common in this corner of Appalachia, one of the nation's unhealthiest regions, a place plagued by poor health habits and sky-high levels of chronic disease that some experts say may be a harbinger of where the country is headed if we don't rein in epidemics like obesity. This week, U.S. Centers for Disease Control and Prevention Director Tom Frieden made a "house call" to find out more about the underlying causes of the region's ills and how to treat them — and in the process gain traction against the rising burden of chronic disease that ails the nation.

"The Appalachian region is just like the rest of the U.S. — only more," said Frieden, who spoke in several spots in the region on the invitation of Republican U.S. Rep. Hal Rogers of Kentucky. "We want to help an entire community and a whole nation."

Appalachia, like some blighted urban areas and Native American reservations, mixes several ingredients of poor health: doctor shortages and access-to-care problems; stressful, unhealthy lifestyles; low education levels; and insidious poverty.

Blankenbeckler, who lives in a small, cluttered trailer just down the hill from the foreclosed-on log cabin her husband built, has at times had to stretch her insulin by taking less than prescribed. Once, her blood sugar spiked to more than four times above normal, but she wouldn't go to the hospital because she had no insurance or money for the bill.

The drivers of poor health so prevalent in Kentucky are simply "concentrated versions of the same factors that we're dealing with everywhere," says Benjamin Sommers, assistant professor of health policy and economics at the Harvard School of Public Health.

"It's about proportion and intensity rather than something unique that's happening there," adds Jesse Roman, chairman of the Department of Medicine at the University of Louisville. "The problem is larger and more visible there, but they're not alone."

'A SAD STATE HERE'

Cancer, for example, touches nearly every American family. But in Kentucky, it strikes and kills at the nation's highest rate and is often diagnosed late.

Suzanne Gibbs, who grew up in the tiny town of Barbourville, Ky., was only 23 when doctors diagnosed her with colorectal cancer. She endured chemotherapy and radiation that took away her ability to bear a second child, leading her to adopt a son.

"I ignored my symptoms for a couple of months," says Gibbs, 29, a teacher who had no known risk factors for the disease and doesn't know why she was stricken.

Other chronic diseases are just as prevalent here. Heart disease prevalence is 84% higher than the national average, diabetes is 47% higher, and lung cancer kills at a rate 83% higher — and some of these numbers continue to rise.

"We're in the stroke belt, the diabetes belt, the coronary valley. We get all those labels," says Fran Feltner, director of the University of Kentucky Center of Excellence in Rural Health. "We're in a sad state here."

Highest-in-the-nation smoking rates are one reason. Nearly a third of adults here smoke cigarettes, and those numbers have remained mostly level even as they've dropped nationally. And in a place where people used to grow, harvest and can their own food, many people now live far from well-stocked grocery stores and turn to convenience items, fast food and Mountain Dew.

"That's why so many of us are so big," says Blankenbeckler, who admits she's always been heavy. "We eat what we got."

Compounding matters, screen time has largely replaced outdoor time, and illness further limits activity, hastening a downward spiral.

For Blankenbeckler, diabetes, bowel and bladder problems and the oxygen she uses while sleeping or sitting for long periods make it difficult even to handle daily chores. Her husband, Tony, 49, also has problems getting around since a 2010 lightning strike, which ended his career as a pipe fitter. He takes 11 pills a day; she takes 30.

"I fix his medicines," Alisha Blankenbeckler says. "I put on his socks because he can't put on his socks. But I can't do a whole lot of things."

She recently gained insurance through the state's Medicaid expansion, while Tony has Medicare. But insurance has not guaranteed access to all the health care they need. They still struggle by on $1,427 a month in disability payments, which makes it difficult to afford co-pays, the medical equipment that their insurance doesn't cover or even gas to get to the doctor. Over the years, they have depended mightily on the help they receive from Kentucky Homeplace, a University of Kentucky program that aims to provide access to medications and medical and social services.

Despite the fact that about half a million Kentuckians have enrolled in health insurance through the Affordable Care Act, "access to health care is difficult in Appalachia," Roman says. "And there seems to be something about culture — a sense of fatalism, that whatever happens, happens."

FINDING CURES

Sommers and Frieden say improving the health of Appalachia and similarly unhealthy regions and populations will not be easy, because it depends on changing seemingly intractable socioeconomic disparities and personal health habits.

Roman says the problems will only grow with the increasing gap between rich and poor, which he says "is going to come to haunt us," healthwise, as a nation.

Obesity, meanwhile, is stubbornly rising nationally, spawning diabetes, heart disease and many cancers and spanning all socioeconomic levels. Frieden told a group in Hazard, Ky., that two-thirds of American adults are overweight or obese, and "we didn't have an outbreak of poor self-control. It's our environment."

Michael Karpf, executive vice president for health affairs at the University of Kentucky suggests, "We need another major initiative, like a War on Poverty. Perhaps a War on Obesity."

Frieden, whose talks were part of an effort called Shaping Our Appalachian Region, said outreach and health education is crucial. But he also plans to listen and take cues from local communities about how best to attack their particular health problems. If he finds an effective program, he said, he will replicate it and fit it to other communities.

"If you've got a big problem and you don't know what works, then you try things," he said. "You figure out what works."

During this week's talk in Hazard, he helped announce a new, $1.5 million, five-year project to promote screening and chronic disease prevention in the region. The CDC is working with the Appalachian Regional Commission and University of Kentucky on the project, which will which help patients with chronic disease navigate the health care maze.

As for other solutions, "it's up to you to figure out what you want to pursue," said Frieden, who recalled doing volunteer health work 30 years ago in Appalachia. "We're here to walk with you on a pathway to good health."

Feltner says she was encouraged by Frieden's visit: "We don't like being the unhealthiest state," she says. "We need as much help as we can get."

The Blankenbecklers agreed, saying they pray every day for improved health — for themselves and the hills they call home.

"Honey, we've got it tough. Ain't nobody know how tough we got it," Alisha Blankenbeckler says. "But we keep saying things are going to get better, and we hope they will."

Ungar also reports for The (Louisville) Courier-Journal. Follow her on Twitter @Laura_Ungar.