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As we’ve been ramping up for the Hearth of Sap Bush Hollow podcast, I’ve been asking for readers to send any questions you might have.  This one came in recently, and I think it’s an important one to tackle.

Hi Shannon,

Avid reader here.  I’ll be subscribing and patronizing the podcast when it happens.  I’m excited to hear it (THANK YOU!!).  I’d love to hear you tackle rural vulnerability as a topic.  I’ve had several dear family friends who have suffered terrible health problems in rural regions.., and it seems you and your family have some of that figured out with your various health journeys and your embrace of multigenerational living.  I’d love if you could delve into that in more detail and give us some of the challenges and opportunities… — Can connection really be an adequate substitute for the easier access that urbanites enjoy?  I suspect it mostly can, but are there limitations to that?…I’m curious about it as someone who has contemplated adopting a more rural lifestyle one day.

Many thanks for all your offerings!

Mariya, from Baltimore

This is a big subject.  It’s taken me a few weeks to get my head around this.  I hope you’ve got a few extra minutes today to tune in and hear what I’ve got to say.  Some of this will be brass tacks info for affording health care, and some of it will be more philosophical.  I promise that all of it is practical and tried and true.  :

I never believed in the Fountain of Youth, but I’ve long had a habit of believing every book I read on the subject of my health.  And I’ve dragged my family along on those belief trips.  And then, at some point along my journey, I began to discover that for every tome I could find about the benefits of nutrient-dense, farm-direct meat-based diets; I could find another about the benefits of low-fat veganism and meat substitutes.  For every medical procedure my family confronted, I could find articles and books arguing against the procedure.  For every missive I endured about the dangers of cholesterol, I could find articles and books  dismissing them.  For every bit of writing that warned against the dangers of the sun, I could find writings about the dangers of sunscreen.  

In short, in all this, after twenty plus years of consciously attending to my health, I have only one certain conclusion:

We’re all screwed.  

In spite of that, I think I know what you’re talking about, Mariya.  I feel as though, in general, my family enjoys good health.  We eat a farm-fresh diet (I do still believe that’s the healthiest food); we move our bodies throughout the day, and welcome the sun on our faces.  We’re cash poor, but profoundly rich in all the ways that matter:  clean healthy food, pure water, fresh air, low stress lives, meaningful relationships, access to nature.  But a journey down to town tells a different story of rural America.  There’s too much obesity.  Too many oxygen tanks.  Too many cigarettes  Too much poverty.  Our local medical care professionals have their hands full.  Our resources are taxed, and it is hard to attract good doctors to the area (although they do come, for many of the same reasons that our family is here). 

So what, then, are our tactics for maintaining health in the northern tip of rural Appalachia? I’ve given this a lot of thought, and I’d say our strategies fall into four primary beliefs:

1. Health is wealth.  Bob and I were without health insurance long before the Affordable Care Act.  And while it was a tremendous relief to have insurance when that finally kicked in (Bob’s a Type I diabetic, and our insulin costs could run as much as $900/month), I notice that the years we lived without it shaped our attitudes greatly.  We observed that a lot of folks we knew with health insurance through their jobs would forego necessary care if it wasn’t covered under their policies.  

Bob and I saw things differently.  Our health was key to our happiness and livelihoods.  We couldn’t expect anyone to pay. So if we felt we needed care, we simply paid for it.  We didn’t have to wait for an external reviewer to approve expenditures.  Sometimes we paid with turkeys and sausage, sometimes we paid with cash.  Sometimes we had to work with sliding scales.  But by shouldering the responsibility for all our care, we also became connoisseurs of alternative medicine and became savvy about the best massage therapists, acupuncturists, chiropractors, and even Shaman.   We developed a habit of choosing what care worked best for us, rather than passively letting an insurance company decide our health care route.  

These practices wound up serving us well as our business grew; especially with the arrival of the Affordable Care Act.  While lamenting our medical expenses to my accountant one of the many years they exceeded $20,000, he introduced me to HRA’s, Health Reimbursement Arrangements.  This is a type of employer-funded health benefit plan that lets a business owner reimburse employees for out-of-pocket medical expenses.  With a little legwork, my sole-proprietor writing business got an employer ID and hired Bob on to handle many of the tasks he was already doing for free:  shipping books, media production, editing, etc.  We set up a formal Health Reimbursement Arrangement through a special company that helps to make sure we’re accounting correctly*.  That HRA enables my business to reimburse Bob for the out-of-pocket medical expenses for himself and his dependents (including me, his wife).  Bob gets a small salary, and the remainder of his income comes in the form of health reimbursements.  Plus he gets to sleep with his boss.  

And as Bob’s employer, I get to allow all the medical expenses that a traditional insurance plan wouldn’t cover:  acupuncture, chiropractic, dental, eye glasses, our daughters’ vision therapy, massage, even medical mileage.  

This plan lets us pay for our medical expenses with pre-tax income.  That, then, improves our eligibility for free or low-cost health insurance.  And that’s how the insulin and conventional care is covered.  

But the Health is Wealth belief plays out in other ways, too.  Last winter when our family came down with the flu, we shut the cafe and gave ourselves time to recover.  

We eat home-cooked farm-fresh meals every day of the year. 

We believe in the health benefits of napping.  

We spend hours in the woods every day, disconnected from cell phones and connecting to each other.  

We don’t get a lot of cash income.  But we do get the time and resources to care for our health.  That’s far more important to us than dollars. 

2. Connection Matters.  Mariya, you hinted at this in your letter, and I’m going to confirm it.  I see the benefits of community and connection every single day.  My mom and Dad have a lot of wisdom and experience.  When I’m flying off the handle with stress and worry, they have the ability to pull me back to earth.  They hug me, let me cry, and believe in everything I do.  Mom and Dad, however, can get swallowed up by their own worries and fears.  They come up to the house for Sunday dinner, and their granddaughters throw their arms around them and want to talk about their week’s adventures.  It pulls Mom and Dad right out of their heads.  And as Mom and Dad go through the process of aging, Bob and I are beside them, talking to doctors, advocating through hospital stays, bringing them back to our house after surgeries, cooking meals, sitting with them through their own tears and frustration, helping them move through it.  

But connection in my neck of the woods is deeper than just family.  Being tapped into a network of customers and community helps me find answers faster.  I share our medical problems openly in my daily conversations, because I’ve learned that I never know who has some experience dealing with a problem we might be facing.  This is how Ula got her vision therapy and special services through the school.  It’s how we’ve found surgeons, cardiologists, chiropractors, acupuncturists, massage therapists, you name it.  

And it’s how we’ve gotten to diagnoses fast.  Our family doctor has long been one of our farm customers.  When Bob started losing weight inexplicably in 2010, she noticed that a nurse practitioner on her staff was diagnosing him with Type II diabetes.  She removed that practitioner from his case and burst into our examining room and said words to my husband that I’ll never forget:

“I know you, and I know how you live.  There’s no way this is Type II diabetes.  You need insulin.  Now.”

I may not have access to all the specialists in a city, but I have a doctor who I have come to know and trust because she plays in the pit for the musicals that my husband and kids perform in.  She comes to the cafe once a month to have breakfast with her daughter.  When my family goes to her with a problem, she responds with an understanding of us and our lifestyles.  That’s a level of care that only community and connection can allow.

And it doesn’t stop with our family.  Running a community cafe, I know many of the health challenges faced by my customers.  We have special off-menu foods that we keep on hand; whether its bone broth for a customer who’s recovering from the flu; or fatty foods to help someone who comes in after a seizure.  If they’re too sick to come in, my customers call or write and ask for soups and broths when they can’t cook.  

But the coolest thing of all, is watching how many people come in right after surgeries and other major medical incidents.  They sit down and from the back kitchen, I watch all the other customers engage in the art of healing.  They move tables and chairs to help each other, they offer sympathy and hugs, and before long, the laughter and jokes that expedite healing are zinging around the front of the house.  

It is through watching all this; both in the family and in my place of business, where I’ve learned the two remaining lessons for maintaining health here:

3.Illness can be it’s own gift.  Having lived in the same community for 40 plus years, I’ve seen a lot of illness and tragedy up close.  In a small community, tragedies and obituaries aren’t merely topics for newsprint.  We often know the victims and families first hand.  And the more I witness, the more I do honestly conclude, as I said above, that we’re all screwed.  But I’ve also come to fear it all less.  Nothing bad transpires without leaving powerful medicine in it’s wake:  new friendships, deeper relationships, self-knowledge.  We can’t get to these things without the vale of tears.  But while we’re passing through it, there is one final lesson to remember:

No matter where you are, 

Love is the best medicine.  

I’ve felt my own heart stop racing while hugging a baby.  I’ve watched my mother’s face melt and warm as my daughters put their arms around her.  I can see my children revive with a home cooked meal.  I’ve felt nourished and restored with the gift of a homemade cookie (even if I’m supposed to be eating ketogenic and paleo for my health).  I’ve had pain leave my body when a neighbor purposely distracts me with a good joke.  Schoharie County may be far away from the nation’s best cancer centers or heart centers or surgical centers.  But I think we do have the basic building blocks to enjoy a healthy life.  Especially love.

You know, come to think of it, maybe I actually do believe in a Fountain of Youth.  Maybe it’s here — this moment —When we can be present with those who are on this side of the grass the same time we are.  Maybe it’s not about trying to live forever, but being forever present, drinking from this life while it lasts, offering the best of ourselves, and accepting the same from our family and neighbors.  Perhaps the Fountain of Youth is more a state of mind; and it can be found wherever we live, as long as we’re open to discovering it. 

Thanks for sending in your question, Mariya.  I’ve really enjoyed thinking about it and learning from it.  I hope this answer helps.  

*If you feel like an HRA might be a good option for you, I’ve had good luck working with either of these companies for managing it:

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