Chapter 38 Quiz: Health, Despair, and Resilience — Healthcare from Company Doctors to Rural Hospital Closures

Multiple Choice

1. The "granny women" of Appalachia were:

a) Professional physicians who practiced in mountain communities b) Women who carried empirical healing knowledge passed through generations, serving as healthcare providers, midwives, and herbalists in communities without access to trained physicians c) Nurses employed by the Frontier Nursing Service d) Social workers assigned to mountain communities during the War on Poverty

2. The fundamental conflict of interest in the company doctor system was that:

a) Doctors were paid too much by the coal companies b) The doctor was employed and paid by the coal company, creating pressure to minimize diagnoses, return miners to work quickly, and avoid findings that might create liability for the company c) Miners had too many healthcare options to choose from d) Company doctors received their training at government-funded medical schools

3. Mary Breckinridge's Frontier Nursing Service (founded 1925) was revolutionary because:

a) It was the first hospital built in Kentucky b) It brought trained nurse-midwives to remote mountain communities on horseback, providing community-based maternal and child healthcare that achieved outcomes far better than the national average c) It replaced all company doctors in the coalfields d) It was funded entirely by the federal government

4. Health disparities in Appalachia include all of the following EXCEPT:

a) Higher rates of diabetes, heart disease, and certain cancers b) Higher maternal mortality rates c) Health outcomes that are better than the national average in every category d) Severe mental health access gaps and dental health crises

5. The "deaths of despair" framework (Case and Deaton) describes:

a) Deaths caused by natural disasters in mountain communities b) Increased mortality from drug overdoses, alcohol-related liver disease, and suicide among middle-aged Americans without college degrees — concentrated in communities experiencing economic collapse c) Deaths caused by mining accidents d) Deaths caused by hospital closures

6. Rural hospital closures in Appalachia are driven by:

a) A surplus of hospitals in the region b) Low patient volumes, unfavorable payer mix (heavy Medicare/Medicaid), the refusal of some states to expand Medicaid, and corporate consolidation of the hospital industry c) An excess of physicians in rural areas d) The construction of new, larger hospitals nearby

7. The refusal of several Appalachian states to expand Medicaid contributed to hospital closures because:

a) Medicaid expansion would have eliminated the need for hospitals b) Without expansion, a coverage gap left many working-age adults uninsured, depriving rural hospitals of the revenue that insured patients would have generated c) Medicaid expansion was irrelevant to rural hospital finances d) All Appalachian states expanded Medicaid immediately

8. Community health workers are effective in Appalachian healthcare because:

a) They replace all other healthcare providers b) They are trusted community members who share the language, culture, and life experience of the people they serve, providing health education, navigation assistance, and a bridge between communities and the formal healthcare system c) They perform surgery in rural areas d) They are physicians who volunteer on weekends

9. Remote Area Medical (RAM) events reveal that:

a) American healthcare is equally accessible to all citizens b) Significant numbers of Americans, particularly in Appalachia, lack access to basic medical, dental, and vision care and must rely on volunteer-staffed free clinics for services that the existing healthcare system fails to provide c) There is no demand for dental care in Appalachia d) The American healthcare system adequately serves rural communities

10. The chapter argues that health disparities in Appalachia are:

a) Natural and inevitable consequences of living in a mountainous region b) The result of personal choices and cultural values c) The health consequences of specific historical forces — extraction, corporate exploitation, political neglect, and the failure to invest in healthcare infrastructure d) Caused exclusively by the opioid crisis

Short Answer

11. Explain how the Frontier Nursing Service model embodied the principle of "going to the patient." Why was this approach essential in the Appalachian context? How does this principle apply to contemporary healthcare delivery in the region?

12. Describe the relationship between the coal economy's collapse (Chapter 32), the opioid crisis (Chapter 33), and the "deaths of despair" framework discussed in this chapter. How are these three phenomena connected?

13. The chapter argues that "the health of a community is not separate from its history." Using specific examples from this chapter and from earlier chapters, explain what this statement means and why it matters for healthcare policy.

Essay

14. Compare the company doctor system of the early twentieth century to the modern healthcare crisis in Appalachia. In a 600-word essay, analyze the structural parallels and differences. Both systems involve healthcare that is shaped by economic interests beyond the patient's control. What has changed? What has remained the same? What does the comparison suggest about the relationship between economic power and healthcare access?

15. The chapter describes multiple responses to the healthcare crisis in Appalachia: community health workers, free clinics, telehealth, and community paramedicine. In a 500-word essay, evaluate these responses. Are they adequate to the scale of the crisis? What would a truly adequate response look like? What political, economic, and institutional changes would be required?