By Liora Engel-Smith

In many ways, not much has changed since Kay Boykin was growing up on her family’s tobacco farm in rural Greene County in the 1960s.

The family rarely saw the one doctor who practiced in the county, Boykin, now 67, recalled. Boykin and her five siblings helped out on the farm, tending to the oval leaves that would eventually become cigars, cigarettes and chewing tobacco with their bare hands.

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Each year during the late summer harvest a strange sickness settled on the group.

“You feel ill all over,” she said. “You do not run a fever. It’s almost like you’ve got the flu as far as the nausea and the vomiting. … We attributed it to the heat.”

It wasn’t until recently, that Boykin, a third-year student in East Carolina University’s nurse practitioner program, learned during one of her classes that the strange condition has a name: green tobacco sickness, a type of nicotine poisoning that develops when the chemical soaks onto clothes and skin.

That type of specialized knowledge is something that few health care professionals learn at school. It is just one of the reasons that rural health can be challenging. Other hallmarks of rural practice, including the higher rates of people without health insurance and the general lack of health services can be isolating. These and other issues help explain why health care providers tend to practice in cities, where hospitals and specialty services are abundant.

A new scholarship program at the East Carolina University School of Nursing has taken aim at that knowledge gap, training up to 21 advanced practice nursing students a year. Through conversations with farmers, visits to rural counties and courses that tackle issues such as pesticide exposure on farms and other topics unique to rural areas, Dr. Pamela Reis, who created the program, hopes to demystify rural health for these students.

Students stand in front of a military plane listening to a man in a jumpsuit
From left, Dr. Sharona Johnson, HRSA ANEW grant preceptor development coordinator, Katelyn Veal, nurse-midwifery student, and Kelsey Booth, family nurse practitioner DNP student visit the US Coast Guard Aviation Technical Training Center in Elizabeth City as part of a tour to help them learn about rural North Carolina. Photo credit: Conly Evans, ECU College of Nursing.

The program’s first cohort is slated to graduate next spring, and all committed to practice in underserved areas across the state for at least two years, Reis said of the $2.7 million program.

“Looking at the data, it’s clear that we have a primary care shortage, particularly when it comes to taking care of the aging population,” Reis said. “And we’re not going to have enough physicians to meet the need … especially in rural communities because it’s very difficult to recruit physicians to rural communities.”

Nurse practitioners — nurses who receive graduate training on top of their bachelor’s degree  — however, are generally more willing to practice in rural areas and can fill the gap, Reis said.

Her observation bears out in the research that, particularly in primary care, nurse practitioners are more likely than physicians to practice in rural areas. Other research shows rural nurse practitioners are highly satisfied with their work and tend to use more of their skills than in other settings.

Roughly half of the program’s 27-student cohort come from urban areas and have had limited exposure to rural health, she added. The other half include nurses, who like Boykin, grew up in rural North Carolina.

Even with her childhood experience, Boykin says she has learned new things, like the consequences of pesticide exposure. Her father, she said, could not afford to buy pesticides, and that topic was new to her.

“It means that I don’t have mule blinders on anymore, especially if I’m treating that population,” she added.

Bridging the rural gap

Marlowe Vaughan can’t leave her farm — not even for a doctor’s appointment — before she gets her proverbial ducks in a row. Vaughan, 35 and co-owner of Razorback Farms, a hog producer with locations in Wayne and Lenoir Counties, has to think about the thousands of mouths she has to feed — those of the pigs she raises.

A blonde woman in a red dress is bending down to touch two pig snouts.
Marlowe Vaughan, 35, is co-owner of Razorback Farms, a hog farm with locations in Wayne and Lenoir Counties. Vaughan spoke to ECU nursing students about rural life and access to health care. Photo credit: Marlowe Vaughan.

Medical appointments have to be scheduled far in advance, she said, and the work she misses during the visit often waits for her when she comes back. With an average of 37,000 pigs produced on the farm annually, there are rarely breaks.

“I don’t get to just shut it off,” she added. “ It’s not a nine to five job.”

Vaughan is a passionate fourth-generation farmer, but when she steps foot at a medical office, her provider may not understand her life. Earlier this month, she shared her experiences with nursing students in Reis’s program. She talked about mental health and being a mother and a farmer. She also talked about injuries on the job.

Many farmers, she said, find it hard to communicate with the average person, let alone with their medical providers. But when a doctor or a nurse has a sense of the life of a farmer, that conversation can be smoother.

That’s exactly the type of first-hand knowledge Reis believes her students need.

“What makes our students special is that they have this specialized training in rural primary care,” she said. “So they’re prepared to take care of farmers and understand their unique challenges.”

The conversation with Vaughan and other area farmers left an impression on Amy Gee, a nurse practitioner student from Greenville. Gee, 47, said the program helped her understand that simply getting to a provider’s office can be a difficult task for people living in rural areas.

“We are in this rural environment and we have so many people involved in agriculture and we need to understand their work,” she said. “So we can’t tie up days and days of their time, driving an hour to a doctor’s office and an hour back.

“That’s time in their workday that they are not working and that can become detrimental to their livelihood.”

A little change

Reis has enough funding to train up to 84 students over the four years of a grant from the federal Health Resources and Services Administration, and while the students are encouraged to serve in a rural area, they could also choose to work in underserved urban areas to satisfy the terms of their scholarship, Reis said.

Even if all 84 primary-care-providers-in-training were to work in rural areas, the needs of rural North Carolina are orders of magnitude bigger. Federal data designates 87 out of North Carolina’s 100 counties as areas with persistent shortages of primary care providers.

Catherine Barnes is a blonde woman and she is listening to a woman in nursing gear.
Catherine Barnes, middle, and other nursing students visit the ECU School of Dental Medicine Community Service Learning Center in Ahoskie. Barnes is slated to graduate next year and wants to serve migrant workers and other low-income women in rural North Carolina. Photo credit: Conly Evans, ECU College of Nursing.

“It’s never going to be enough,”  Reis acknowledged, but it’s a start.

But one provider can make a difference in a given community. Midwifery student Catherine Barnes, 35, wants to work with low-income and migrant worker families. Barnes, who grew up in a suburb of the city of Wilson, had very little first-hand experience with farming before she participated in the program, but now she understands some of the challenges her future patients may face.

Gee, the nurse practitioner student from Greenville, agrees.

“I absolutely think [this program] should be duplicated elsewhere,” she said. “I feel like through this program we’re building our relationships with the community, with eastern North Carolina. … It really helps you understand what you’re up against.”

This story has been updated to clarify that ECU’s program trains advanced practice nurses, including nurse midwives and nurse practitioners.

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Liora Engel-Smith joined NC Health News in July 2019 and covers policies, programs and issues that affect rural areas. She has previously worked for the The Keene Sentinel in New Hampshire and the Muscatine...

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