State and Local Partnerships for Meeting the Healthcare Needs of Small and Often Remote Rural Communities

Abstract

merican healthcare has been described as a “non-system,” but there have been persistent efforts to coordinate and rationalize how we provide medical care in the United States. These efforts have resulted in what may be called informal systems of care. A perfect example of one of those systems is in North Carolina, a system created for the people of the state’s smaller and poorer communities, communities that are most often rural and more often inhabited by racial and ethnic minority citizens. Almost all of North Carolina could have been called rural at the end of World War II. The 1940 Census classified 72.7% of the state’s population as rural or living in communities with fewer than 2,500 residents. A few cities—Charlotte, Durham, Greensboro, Asheville, Raleigh—had modestly large populations, but no city in the state had a population greater than 110,000. The state’s economy was strongly linked to agriculture, and the prevailing perception of North Carolina was of a sleepy, rural, somewhat backward state. World War II created an economic stimulus for the state when military installations were located in North Carolina— shipyards were established in Wilmington to build liberty ships, and facilities were developed to house prisoners of war in the central and the mountain regions of the state. But the war left another legacy beyond economic benefit: the state had experienced the highest medical rejection rate for its draftees of any state in the Union. The causes for rejection were usually chronic problems related to nutrition and poor or unavailable basic medical care and health advice. This embarrassing fact is often cited as the driver of the statewide “Good Health Campaign” promoted in 1949 by prominent North Carolinians, including Kay Kyser, who recruited radio personalities and Hollywood stars to help raise money and direct attention to the healthcare needs of the state. That public effort had a significant impact, but it built on prior efforts to expand health resources. For years, politicians had been debating whether to assist one or both of the private medical schools in the state (Duke University and Bowman Gray) or whether to create a large medical center by expanding the two-year medical school at the state university in Chapel Hill. Governor Melville Broughton appointed a Medical Care Commission in 1944 to study the health and medical needs of the state. That commission recommended the creation of a new, state-supported, four-year medical school in Chapel Hill that would share space with the existing School of Public Health and occupy space adjacent to a new, comprehensive teaching hospital. After years of consideration, the General Assembly supplied construction funds that were combined with money from the Hospital Planning and Construction Act of 1947, the Hill-Burton Act, to build Memorial Hospital in Chapel Hill and to create the teaching hospital. The Hill-Burton program also supported the construction of many North Carolina hospitals and public health facilities in