1. Way, Daniel MD


A rural doctor's lens on the Adirondacks.


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In my 27 years as a family physician in New York State's Adirondack Park, I've found that family ties are often strongest where money is scarce-families survive by pooling their limited resources and using skills acquired over a lifetime of self-reliance. The original settlers came to the Adirondacks more than two centuries ago, establishing subsistence farms in the wake of mining and logging operations. This 6-million-acre state park has a year-round population of only 140,000 people; Hamilton County, in the center of the park, has a population density of only two people per square mile, making it the least populated county east of the Mississippi River.1 Jobs in many areas are limited to school and government, the wood products and tourism industries, and public works. A family's survival often depends on the timely arrival of a paycheck, with little safety net available in the event of a layoff, a disabling injury, or chronic illness. When such a crisis occurs, the mountains, lakes, and forests can impede access to health care and social services.


The younger generation of Adirondackers has relocated to urban areas; the remaining population is aging and decreasing in number. Many of the people I've treated have a disability or live on a limited income. Second homes for the wealthy and retired have come to dominate the housing market, escalating property taxes and creating a shortage of affordable housing. Rising propane and heating oil prices lead many to rely on wood for heat (if they can split, stack, store, and carry it), despite the fact that old and inefficient woodstoves can cause respiratory problems. Alcohol and tobacco-use rates among year-round Adirondackers are higher than state and national rates. According to Hamilton County Public Health, lung cancer caused 10% of deaths in 2004.


With the nearest health care center or grocery store often as much as 40 miles away, even a trip to the doctor can be a costly venture. But what my patients lack in finances they make up for in selfreliance. They build their own dwellings; hunt, fish, and trap; search out wild ginseng to sell at specialty markets; guide tourists; grow their own foods; and work at many jobs. They wouldn't describe themselves as poor, but their geographically bounded and often strenuous lives at times resemble those of rural Americans several generations ago.


My own experience and that of numerous colleagues suggests that the average income of Adirondack primary care physicians is far lower than that of physicians elsewhere. The average age of physicians continues to rise, and our numbers are rapidly dwindling as our recruiting advertisements go unanswered by primary care physicians who can work fewer hours for far more money in other parts of the country. Although they might visit the Adirondack Park for a vacation, few will settle here to pursue a vocation involving long hours, understaffing, and travel on often treacherous roads to reach patients-despite the sometimes remarkable rewards. While nurses and NPs take up a lot of the slack, they too are often overworked and continue to look elsewhere for more lucrative, less demanding jobs.


On the cover. Every member of the Vincent and Janet Moffitt family has a chronic health problem. The cover photograph features daughter Denise far left), who had open-heart surgery for congenital heart disease at age 13 and has had seven pacemakers implanted in 29 years. Her 20-year-old son Clifford (seated, next to Denise) has a seizure disorder and severe learning disabilities. Janet, standing in the doorway, has osteoarthritis, and her husband Vincent, a former laborer and lumberjack, has had Alzheimer's disease for more than five years. "It hurts to pay the $25 copays every month for each of our medicines," says Janet, "but without Medicaid, we wouldn't have nothing. [horizontal ellipsis] I promised Vince I would never put him in a nursing home." They've stayed on in rural Wevertown despite their home burning to the ground twice in electrical fires.

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"I can go all day in the woods and not feel tired," says John Archambeau. "I like people but I don't like to be close to them all the time. If you have enough money to keep up with your bills, you're fine-more than that, it just causes problems."


John supports an extended family on workers' compensation; he can't afford preschool for grandson Matthew or special education for Matthew's mother, Johnie (second from left), who has a learning disability and can't live alone. John and his wife Nancy (far right) supplement the family diet with fresh fish and game. John, despite extensive arthritis resulting from years of work at a sawmill, does most of the hunting and Nancy most of the fishing. Although John couldn't afford health insurance during his career at the mill, his family now qualifies for Family Health Plus (a New York State program for the uninsured). Still, he and Nancy will have to save for two months to buy the new eyeglasses young Matt needs for amblyopia.


After spending her young-adult years helping her mother rear foster children, Barb Ross dedicated her middle years to caring for her mother after her father and then her stepfather died. When her mother died, Barb found herself alone. She was diagnosed with coronary artery disease in 2004 and offered cardiac rehabilitation at the nearest community hospital, more than 50 miles away. Without a car or public transportation, she couldn't participate. She lives alone in what was her mother's home in Bakers Mills. "This is my home now," she says, "and I can do what I want here." She's pictured below reading the Bible, much of which she's memorized.


Charlotte Springer (above right) lived with her mother Beatrice (left) for 33 years after her father died. At age 76, Bea suffered a stroke that left her with right-sided hemiparesis and severe expressive aphasia. She was my patient for the next 18 years. Like many headstrong Adirondack matriarchs, Bea dictated the terms of her care; Charlotte and I obeyed. Refusing the cost and inconvenience of anticoagulation with warfarin, Bea took only aspirin, digoxin, and antithyroid medication for the rest of her life, while Charlotte cared for her in their tiny home. Bea died at age 94 without having spent a night in a hospital or nursing home.

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Eleanor and Albert Alger met rather late in life, after she had retired from the circus in her mid-40s. Together they shared a spartan yet happy life in a one-room home along the Hudson River above Warrensburg. Unable to support both preventive health care and a heavy tobacco habit, they chose the latter. Although both eventually succumbed to atherosclerosis, they seemed to have no regrets. "We're not poor," Eleanor once told me, perhaps quoting a popular bumper sticker. "We just don't have any money!!" Albert died first, and Eleanor entered the nursing home in North Creek, a communityoriented facility that eventually absorbs many of the area's residents.

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1. Jenkins J, Keal A. The Adirondack atlas: a geographic portrait of the Adirondack Park. Syracuse, NY: Syracuse University Press; 2004.