David Chenault answered a calling years ago when he moved to Phillips County to teach at Barton High School.
He said what drew him was the dire need for math teachers in the Helena-West Helena area.
But Chenault, who was raised in Malvern and taught in both urban and rural schools before going to Phillips County, had no idea what the future would hold when it came to his health.
Chronic obstructive pulmonary disease, chronic pain and heart issues now plague Chenault and he is required to see a list of specialists, but none of them are in that part of the Delta.
"Unless I have a cold, I have to drive to Little Rock for all of my specialist appointments," he said in an August interview. "I can't just take a lunch break and go to my appointment. I have to try to cram them all in on the same day. Anytime I have an appointment, I miss an entire day of work because there is nothing here for me."
This tale is just one of many that are lived every day in the Delta, where the gulf between the haves and have-nots is wider than anywhere else in the state.
For years, statistics have shown that a person born in the Delta of Arkansas has a lower life expectancy than someone born in the urban areas of Central and Northwest Arkansas or even other rural areas. The covid-19 pandemic brought renewed attention to these differences, which are connected to, among other things, access to health care and poverty.
"We are proud Arkansans," Jo Ann Knight Cox, a teacher at DeWitt High School in Arkansas County, said in an interview in August. "We support Arkansas, we root for the Razorbacks, and we are proud of our state, but it's like the people outside of the Delta, they don't seem to be proud of us. They have forgotten us, and we need help."
Kenneth Crosskno, a farmer from Mississippi County who has lived just a few miles outside of Blytheville for his entire life, said living in the rural Delta is just like living anywhere else, except everything you need is 15 to 20 minutes away.
"If it's anything other than what we can get from Walmart, then we go to Jonesboro," he said. "They do have a hospital [in Blytheville] from what I understand is pretty good, but anything other than a family doctor, then we have to go to Jonesboro, Memphis or Little Rock because that is where the specialists are."
Crosskno said he has had to make that emergency drive to Jonesboro multiple times.
"All three of my kids were born in Jonesboro," he said. "My wife would go into labor, and we would get into the car and drive 45 minutes or an hour and hope we make it on time. It's a concern but we have adapted quite well. We just know what we got to do."
Mellie Bridewell, president and CEO of the Arkansas Rural Health Partnership at the University of Arkansas for Medical Sciences, said the challenges like finding medical specialists shouldn't be considered a part of living in a rural area of the state.
"These differences [in health outcomes] are a result of imbalanced systems that negatively affect people's access to healthcare, their health condition, and ultimately their living condition," Bridewell said in an email. "All of this is avoidable with the right systems in place."
"Health inequity" and "health disparity" became popular terms used by experts examining who was affected the most by the covid-19 pandemic that has plagued the country for nearly two years now.
The health inequity in the Delta has been known for much longer.
"[B]efore we founded Arkansas Rural Health Partnership and began to grow, there was no advocacy group or voice for rural healthcare and our providers," Bridewell said in an email. "Consider this: up until last year, Arkansas was one of only six states in the country without a statewide rural health association, and it is still one of only a handful of states with no rural health clinic association. That is a problem and what I believe to be one of the driving factors in the lack of change in our health statistics over the past decade."
Earlier this year, the University of Arkansas Cooperative Extension Service released the 2021 Rural Profile, a report that outlined a dire situation for those counties.
"What we are seeing in rural counties over the years is not just a decline in population, but also a decline in the economy, in health and in services," Robert Scott, director of the University of Arkansas Cooperative Extension Service, told the Arkansas Democrat-Gazette.
The Rural Profile is a biennial publication spanning three decades. It describes social, demographic and economic trends in rural and urban regions of the state.
The major focus of the profile remains understanding the differences between rural and urban areas, as well as describing how conditions vary within the rural areas.
Scott said the data profile is meant to be used as a tool for leaders in planning and directing policies and programs, as well as provide a valued source of information for elected leaders in state and local governments.
The Rural Profile outlined a grim situation that has faced the Delta counties for decades as their population, economy, infrastructure and health outcomes all lagged their urban counterparts.
"This is not only a medical problem," Chenault said. "It's a business problem, it's an education problem, it's a federal and local government problem. There is such a broad lack here it's going to take assistance from a whole plethora of agencies, groups, businesses and more working together to bring us out of the 1800s.
The Rural 2021 Profile stated the rural areas of the state ranked low in health factors and outcomes compared with their urban counterparts.
The Rural Profile used data from the Robert Wood Johnson Foundation's County Health Rankings, which combines multiple indicators to create a two-score system: health factors and health outcomes.
The Health Factors score measures underlying contributors to public health -- for example, health behaviors, clinical care factors, social and economic factors, and physical environment.
The Health Outcomes score measures the major health results that people experience, for example, length and quality of life.
To define the Delta, the Arkansas Democrat-Gazette used the Delta Cultural Center's list of 27 counties: Arkansas, Ashley, Chicot, Clay, Craighead, Crittenden, Cross, Desha, Drew, Greene, Independence, Jackson, Jefferson, Lawrence, Lee, Lincoln, Lonoke, Mississippi, Monroe, Phillips, Poinsett, Prairie, Pulaski, Randolph, St. Francis, White and Woodruff. The Rural Profile used a somewhat different list.
The 10 counties with the worst health factor scores are in the Arkansas Delta: with Phillips last, then Lee, Mississippi, St. Francis, Chicot, Desha, Jackson, Monroe, Poinsett and Woodruff.
The counties with the best ranking were Benton, Saline, Baxter and Washington counties.
On health outcomes, counties in urban areas had better scores, while those in the Delta and Coastal Plains had the worst scores.
Eight of 11 counties with the worst health outcomes were in the Delta.
Dr. Brookshield Laurent, the executive director of the Delta Population Health Institute in Jonesboro, said the Delta, because of its rural settings, has its own set of complexities.
"There are differences in infrastructure, education, and more when it comes to health outcomes," Laurent said. "You also can't leave out the historical context of the area. The historical injustices of the Black and people of color in the Delta region plays a part. These historical contexts affect the environmental status of the people who live there."
Quinyatta Mumford, who is the section chief for rural health for the Arkansas Department of Health, said there are gaps in health care access in Arkansas.
"They have been long-standing, and the pandemic just amplified that," she said.
For example, Cox said DeWitt is served by Baptist Health Medical Center in Stuttgart, a few small satellite clinics, a local doctor's office and nursing home, but only one mental health clinic.
Mumford said health inequity can be attributed to age, household income, lack of health insurance and health quality.
"When you compound these things with the issues you see with race, then you see health inequity," she said.
Data provided to the Arkansas Democrat-Gazette from the Health Department showed that there are several primary care health professional shortage areas, and most of them are in rural areas.
The data used scores developed for the National Health Service Corps to determine priorities for the assignment of clinicians.
Scores range from 1 to 25 for primary care and mental health. The higher the score, the greater the priority.
Fourteen counties had a score of 17 or higher. They included Chicot, Lee, Crittenden and Poinsett, in the Delta.
"Health care gaps can occur when you don't have access to physicians, and a lack of transportation just complements that," Mumford said. "A health care shortage occurs in counties where they have 3,000 to 1 patient access. This overburdens an area."
These problems are compounded by the lack of medical education and available services.
"I was in Monticello for a workshop, and I remember I noticed I couldn't see very well so I went to a primary care physician and got my blood sugar checked and it turned out I was Type 2 diabetic," Cox said. "He just gave me medication and told me to eat fruit. That was it. There are no education services here if you have diabetes. If you have heart problems you can't get any information about your diagnosis. Thank God, I can Google."
OBESITY IN THE DELTA
In fiscal 2018, 71% of the adult population in Arkansas was categorized as overweight or obese by the University of Arkansas Cooperative Extension Service with 85% of the adult population in rural counties labeled as overweight or obese, compared with 62% in urban counties.
In 2019, 23% of children in Arkansas were considered obese and 40% were considered either overweight or obese -- 25% were obese in rural counties, compared with 22% in urban counties.
Rural counties have a higher share of people who are over age 65, identify as minorities and are considered obese.
Mumford said high obesity is one of the main drivers of chronic disease and is a driver in some of the statistical differences between rural and urban categories.
"This is why you see the counties in the Delta performing the lowest in county health rankings," she said.
These statistics help explain why residents in rural counties are at a greater risk of hospitalization and death from covid-19.
The Rural 2021 Profile reported numbers from Nov. 25, 2020, that showed 93 covid-19 deaths per 100,000 in rural counties, compared with 71 per 100,000 in urban counties.
The Delta region had the highest rate, at 116 covid-19 deaths per 100,000, followed by 101 in the Coastal Plains region and 82 in the Highlands region.
Bridewell said Arkansans must do better as a state by prioritizing rural health care and by acknowledging the struggles and lack of resources faced by rural providers.
"We need passionate people with a rural perspective on health care at the table, and we need health care organizations led by board members who bring that viewpoint to the overall conversation," she said. "And then we need those leaders to be willing to make the changes necessary to create a healthier community. After all, it's hard to effect change when you don't know what changes are needed – or you're isolated and lack the necessary resources."
FEWER JOBS, LESS MONEY
In the aftermath of the 2008 recession, Arkansas' economy, as measured by total employment, grew at half the rate of the national economy from 2010 to 2018, 9% versus 18% nationally, according to the Rural 2021 Profile.
The state's urban regions saw employment increase 13% from 2010-18 while employment in rural regions remained stagnant and below 2007 levels, the profile states. Although some rural areas saw new jobs created, most struggled to have those that attract and keep residents.
Although the recession took a toll on jobs across the state, 39 of Arkansas' 75 counties had net employment gains after the recession, from 2010-18.
The highest rate of job growth occurred in counties that were in or surrounding the urban areas of Northwest, Northeast and Central Arkansas.
But slightly more than half of all rural counties lost more than 5% of their jobs from 2007-18.
In 2018, average earnings per job in rural areas was 13% lower than in urban regions.
The same year, rural counties had an average median household income of $39,000 that was 20% lower than the $49,000 income in urban counties and 35% lower than the national average.
The economic situation in rural counties is compounded by infrastructure that is lacking compared with urban areas.
"There is nothing between Little Rock and Memphis," said Chenault, the Helena-West Helena teacher. "You get on the interstate, and Brinkley and Lonoke are just bumps in the road, but nothing is here to support a major hospital or justify a heart doctor or heart clinic."
The Rural Report showed that providing critical infrastructure is difficult for rural counties that have a decreasing ability to generate local tax revenue.
"If there is no gym in your area or no safe place to walk or there are no grocery store options, then you have limited choices in living a healthy lifestyle," Mumford said. "Compound that with lack of transportation, lack of insurance, and then it's a perfect storm."
Bridewell said Arkansas needs to address the need for rural transportation and strategically build access to services and care.
Cox moved to DeWitt more than a decade ago, and during that time, she has learned about the challenge of finding mental health services in a rural town.
"I have seen problems with students not being able to get mental health services in a timely manner," she said. "We have a mental health clinic in Stuttgart, but it's 35 minutes away, and they are so overwhelmed with patients from all over the region they can't get services in time."
Cox said she has seen students be diagnosed with mental health problems, but never receive any follow-up care.
"They get placed on medication, but there is no follow-up counseling because there is no counseling here," she said. "They get 30 minutes once a week from the school counselor or social worker, but the children need more help than that."
Arkansas is frequently among the states with the highest levels of social and economic stress indicators, and the rural region of the state has consistently had higher levels of economic stress than the urban region.
"When you see these types of declines it always a snowball effect," Scott said. "One thing goes out of business and another goes, and no jobs are available and then the young people leave."
Crosskno said farmers in the Delta deal with multiple stressors, but one of the biggest is workers.
"It's just hard to find qualified labor, and when you find it, it's hard to keep it," he said.
Crosskno said farmers looking for workers who are trained to use farm machinery have to compete with higher-paying industries for qualified labor.
"The agriculture industry can't compete with the steel mills here," he said. "We can't compete with the wages that they have. Any qualified labor we had here has gone to the factories so we are always searching."
Crosskno disagrees with the notion that mechanization meant farms needed fewer people.
"My opinion on the mechanization of farms is that we have always had the need for people. We started running out of people so we had to become more mechanized," he said.
"I have had to search for people to work," he said. "I haven't had anybody come looking for a job at my farm in two years. We have to turn to mechanization to prevent the farm from not operating and to keep it from going under since the labor is not there."
This mechanization comes with its own set of employment problems.
"We have to invest in bigger machinery to try to do the same amount of work with less people, and of course that comes at a cost because we have to have more experienced people and more qualified since the equipment has become more high tech," he said. "We can't just put anybody back there anymore because it's more than putting someone in a tractor and moving gears and turning a steering wheel."
Arkansas, which has a population of about 3 million, has more than 510,000 people, including more than 171,000 children, who lived below the federal poverty level in 2018.
Rural counties had a 20% poverty rate, which was four percentage points higher than urban counties.
The Delta had the highest poverty rate, at 23%.
TalkPoverty.org, a project of the policy institute known as the Center for American Progress, stated in 2019 that the state's percentage of people who had incomes below the poverty line was 16.2%, or 474,739 residents, ranking Arkansas 47th in the nation.
Blacks had the highest percentage of people in poverty in the state, at 27.1%, followed by 20.6% for people who identify as Hispanic.
Factors such as access to grocery stores, income levels and job availability contribute to increased rates of food insecurity, or not having access to enough nutritious food.
While urban areas had a 20% rate of food insecurity, rural areas were at 26%.
The Delta had the highest level of food insecurity in Arkansas -- 30%.
In 2019, 38% of Arkansas children living in rural areas received aid from the Supplemental Nutrition Assistance Program, compared with 29% of those in urban areas.
"If our students and families need any kind of help as far as SNAP benefits or state services they have to go to Stuttgart, and then the caseworkers are so overloaded it takes a long time to get help," Cox said. "I kind of resent the fact I spend taxes, and I don't see my tax dollars at work here."
Over a 10-year period since the 2009-10 school year, school enrollment grew 10% in urban regions but dropped 7% in rural areas.
The Delta witnessed a 15% decline in public school enrollment. In particular, Lee, St. Francis and Monroe counties in the Delta lost 25% of their student enrollment.
Lower student enrollment decreases some forms of school funding, while many costs for public education are fixed, such as school facility maintenance and staff salaries.
To overcome shrinking populations, decreased funding and rising costs, public school districts are often forced to merge into large school districts.
In rural counties, 16% of adults lack a high school diploma or equivalent, compared with 12% in urban counties.
The Delta rate of adults without a high school diploma was 19%.
"One of the things you are fighting here is the lack of the importance of education," Cox said. "Self education and public education."
"In order for us to have a strong rural health system, there must be the ability to build a locally grown health workforce," Bridewell said. "People rarely just pick up and move to a small rural community with a poor educational system and few resources."
Cox said DeWitt has a strong community that needs services and investment.
"We just need help," she said. "I think we deserve the chance to become better again."
Chenault said living in a town like Helena-West Helena can be tough, but there are nice things about it as well.
"This is a place you don't move to on a whim," he said. "You move here knowing what you are going to face, and you stay here knowing what you are giving up and what the challenges are, but it can be worth it."
Chenault said the Delta might not be perfect, but it's home to many.
"It may seem like the answer might be obvious to other people who are looking from the outside, but change is difficult and not always as obvious when you are on the inside of it," he said. "You like the way your house is and when other people come to your house you don't want them changing it. That is sort of the situation in the Delta. Once they [current Delta residents] understand why the change needs to happen, they will get on board but the initial response will be, why are you changing my home?"
Bridewell, of the Arkansas Rural Health Partnership, said she believes there is a solution to health inequity in the rural Delta, and it will take time and resources.
"We're already making a difference through our organization's efforts and the efforts of our educational partners," she said. "It can be done, but we must work with our local schools and government agencies to bring change through our youth."
Bridewell said solutions must include cutting operating costs for small, individual hospitals and clinics but operating them as a larger entity together while maintaining local governance.
She also called for addressing health care needs through innovative projects and growing their own health care workforce through initiatives directed at youths.
"A lot of our Arkansas economy is driven by farming, poultry, etc.," Bridewell said. "We should be thankful that there are people who choose to live in rural and agricultural communities -- in fact, we should make them a huge priority in our efforts to keep them healthy. Our state economy depends on them."