An outbreak of the highly contagious intestinal bug known as norovirus has been raging through North Canton Elementary School over the past two weeks, but illness now seems to be on the downswing — to the relief of parents and teachers alike.

To build a fence or to not build a fence? 

It might not seem like such a portentous question, but as Sylva Town Commissioner Mary Gelbaugh found out when she asked her Facebook friends whether the town should look at putting a fence along Scotts Creek through Bridge Park, it kind of is. The comments came so thick and fast that Facebook contacted her to see if someone had hacked her account.

Don’t light, chew, smoke or spit that tobacco in Jackson County parks, and if you do, you could be slapped with a $50 fine. That is the gist of a proposed law that will soon be voted on by county commissioners.

Joyce Porter had just finished cleaning her house in Jonathan Creek and was planning to hop in the shower, but when she turned on the faucet, no water came out.

The numbers are unforgiving.

One in three unexpected deaths in Haywood County are likely prescription drug overdoses. This year alone, there have been eight drug-related deaths — out of 25 unexpected deaths in all. And that doesn’t include two deaths last week that the county medical examiner suspects are overdoses as well. 

After enduring months of dogged opposition over a county rule that would protect residents from nasty garbage piles on their neighbor’s property, Haywood County leaders are trying a different tack.

The county has dropped the idea of a public health rule governed by the health department and instead will draft a health ordinance. An ordinance will allow more flexibility, while a rule under the auspice of the health department had to conform with state mandates.

Haywood County Commissioner Mark Swanger recommended the new approach, which garnered unanimous support from the rest of the commissioners.

Swanger said some sort of mechanism is necessary to protect people from unhealthy situations created by neighbors.

“It has nothing to do with aesthetics or that you just have a messy yard. It would have to be a demonstrated health risk,” said Swanger.

The scrapped health rule chiefly dealt with garbage that might attract disease-carrying rodents and mosquitoes, but would have also applied to an abandoned swimming pool that had become a health risk or a chemical spill, for example.

While some opposed the spirit of the ordinance as meddling in the private property arena, others merely took issue with over-reaching enforcement and over-the-top punishment.

The rule allowed the health director to come onto private property without permission and offenders could have been charged with a class I misdemeanor.

Wording was changed to require the health director to first get a search warrant except in the case of an imminent hazard. But little could be done about the class I misdemeanor for violations, as that was the punishment mandated by the state. If written as an ordinance by the county, however, it could carry a lesser charge of a class III misdemeanor, Swanger said.

A small task force has been appointed to provide input on writing the ordinance, including two critics of the health rule in its original form.

One of those, Terry Ramey, said he hopes the new approach will help “bring people back together instead of being mad at each other.”

Ramey said too much bad blood exists between the critics of the rule and members of the health board for a compromise to be reached.

“It had gotten to a head-butting deal,” Ramey said. “It just got out of hand.”

Ramey said he is not against an ordinance in principle.

“We need something,” Ramey said. “Let’s say somebody had trash piled up and it was rotten and it had insects and stuff in it. We want something in place for situations like that. Even the people against it don’t want a really bad health hazard.”

But Ramey said the original rule left too much room for broad interpretation.

On Monday morning, Haywood County commissioners listened as one citizen after another came up and blasted a change to a health board rule that has been on the books since 1970.

About 40 people stood up to express their opposition to the rule when one speaker asked for a show of support.

Citizens accused the commissioners of backhandedly reviving a nuisance ordinance that had already been stamped out by public outcry.

“You asked the health board to do your dirty work,” said Lynda Bennett at the meeting. “This is a very, very unpopular ordinance.”

The rule that’s now in question chiefly deals with safely storing garbage that can attract disease-carrying pests. Its most controversial aspect is a measure that allows the health director to step onto private property in the case of an imminent hazard — something that is already permitted under state law.

Another component of the ordinance that’s up for debate is the maximum penalty for a Class 1 misdemeanor for not storing garbage safely and creating a health risk for others — another issue that’s been set by the state, according to Chip Killian, Haywood County attorney.

“The statues are there, we need to enforce them,” said Commissioner Skeeter Curtis.

Haywood’s health board was ready to vote on the amendment with little ado in January when a crowd of 75 showed up to voice strong opposition.

After months of addressing citizens’ concerns and altering wording on the rule, the health board is now ready to vote on the amendment on Tuesday, Aug. 10.

Citizens rallied together once more Monday to express their fury concerning the measure, which they see as an unconstitutional violation of property rights.

“My only concern right now is our freedoms,” said Catherine Jones. “Little by little and on all levels, our freedom is being chipped away.”

Some speakers pointed out that commissioners up for re-election this year might feel their objections come fall, unlike the many health board members who are appointed, not elected.

“They cannot be held accountable at the ballot box like you can,” Bennett added.

Responding to certain concerns, the Haywood health board already amended its amendment to the rule to say the health director must always try to get a search warrant before entering property unless there is an imminent threat.

Commissioner Mark Swanger, who serves on the health board, said to his knowledge, no one has ever been arrested, fined or had their property entered without a warrant in the 40 years the health board rule has been in effect.

“Now what more can anybody ask for?” said Swanger.

Later, Swanger gave an example of when the rule would come in handy. He pointed out that trucks carrying nuclear waste constantly pass through the county on Interstate 40. If one should get in an accident, run off the road and spill toxic waste on private property, health authorities should be allowed to enter and abate that threat immediately.

“I see people smirking,” said Swanger. “If it were your backyard, you would wish they would help you.”

Commissioner Kirk Kirkpatrick added that this was in no way an attempt to violate people’s constitutional rights. He had his own example for the rule’s utility.

If a child gets sick playing in a filthy yard with feces and other health risks, there would be little health authorities and law enforcement could do without the rule. A worried mother’s only recourse would be to pursue expensive legal action.

“You guys can say it’s farfetched, but it’s certainly possible,” said Kirkpatrick. “Without this particular rule, there’s nothing the county can do.”

Kirkpatrick also emphasized the difficulty of penalizing violators with a Class 1 misdemeanor. He said such cases are extremely difficult to prosecute and the last thing Haywood County wants to do is spend money to enforce the rule. The health department will instead cooperate with violators right off the bat.

Have your say

The Haywood County health board will vote on the controversial amendment to its solid waste rule at 6 p.m. on Tuesday, Aug. 6, at the county health department.

For the past year or so, Sylva Mayor Maurice Moody has been focused on cleaning up his town.

“We’ve been talking about it for a long time, and in the last year we’ve made significant progress,” Moody said.

The city’s health and sanitation ordinance says the town can order property owners to clean up public health nuisances on their property within 24 hours of being notified of the hazard. The so-called hazard abatement ordinance draws its force from state statutes that outline the rights of property owners and municipalities in the cases of public health nuisances.

In the past year, the town has gotten nine property owners to clean up perceived health hazards that range from rusting hulks of trailers, to piles of junk parts, to old tires in yards. Businesses haven’t been exempt from the push either, with Jackson Paper and a local auto repair shop making the list.

In town, the nuisance abatement program is considered Moody’s pet project, since he has pushed the stalled conversation forward.

Sylva’s updated list of residents with health risks on their property identified between 2009 and the present contains 17 names, and nine of the nuisances have already been abated.

The way the program works is that members of the town staff or board identify potential nuisances. In the event that there is confusion over a property, the town’s attorney, Eric Ridenour, evaluates the site and makes a determination about the town’s legal ability to enforce the ordinance.

The town then sends legal notice in the form of a letter from the town manager to the property owner to clean up the health hazard. Upon receiving the letter, property owners have 24 hours to start the process of eliminating the nuisance.

Not everyone is thrilled with the program.

William Woodring was cited under the ordinance for junk car parts in the yard of his Rhodes Cove property.

“I don’t think it’s a health concern if it’s car parts,” Woodring said. “If it was trash, they might have something.”

Woodring said he got the notice in the mail, and was never spoken to in person. His mother died at the beginning of the month and much of the junk belonged to his brother, who was living in a trailer with his mother. It was a difficult time to get things cleaned up.

Woodring agreed to clean up his property, but he wonders whether the program is really about removing health risks or people making assumptions about other people’s property.

“I guess it’s just people nosing around and saying that’s junk,” Woodring said. “Some people’s junk is really worth something. Somebody ought to come talk to me about it anyway because I do pay my taxes.”

But Moody is unapologetic about the program.

“It’s certainly a health and sanitation thing, but it’s also an appearance thing,” Moody said. “What you do in your backyard does make a difference.”

Moody said that as land tracts in town get smaller, the effects of health nuisances on neighboring properties are accentuated. He allows that some people might object to the idea of being told to clean up their land.

“Some people might feel that way, but I don’t think our ordinances violate anybody’s property rights,” Moody said.

Commissioner Chris Matheson said the program isn’t designed to harass people or enforce aesthetic standards. She said calling people on the phone or talking to them doesn’t qualify as legal notice, and the town does what it can to help property owners clean up their land, including offering yearlong extensions in certain cases.

“We don’t go through the final steps without really trying hard to work with the property owner. It’s really just about getting the health nuisance cleaned up,” Matheson said. “There’s also grounds for someone who feels like it is just an aesthetic issue and not a health abatement issue to challenge it.”

In the end, the program relies on cooperation from property owners, and its record of success has shown that most people are willing to clean up health hazards on their land if they are given enough time to do it.

A pivotal moment arrives every time a pregnancy test turns positive at public health departments across the state.

The new mother could walk out the doors, overwhelmed and underprepared, never to return again. She could receive little or no prenatal care before delivery. She could possibly die.

Or, she could pay absolutely nothing for prenatal care, delivery and 60 days of postpartum care. Not to mention, childbirth and parenting classes, one year of Medicaid for her newborn child, family planning services, and even emotional support and advice throughout the pregnancy.

It’s a moment that nurses at Haywood and Jackson County health departments don’t take lightly.

“That’s where we grab them,” said Vicki James, maternal care coordinator for Haywood for the past 11 years.

“We really have the nurse literally come knock on my door as they get their positive pregnancy test,” said Courtney McLaughlin, Jackson’s maternity care coordinator. “As soon as we get them, we connect them to all these services.”

North Carolina has come a long way in providing support to low-income women, bringing them closer to the reality of an uncomplicated pregnancy and a healthy baby.

Moreover, Medicaid for Pregnant Woman extends generous financial aid to women who don’t usually qualify for regular Medicaid.

Yet a study released this month by Amnesty International, a human rights group, shows a major gap still exists in care given to pregnant women across the state.

The report states 15.7 percent of women in North Carolina still receive delayed or no prenatal care, equivalent to about one in six women. That number jumps to nearly one in four among women of color.

Amnesty International claims that women who do not get prenatal care are three to four times more likely to die than women who do.

With 11.4 mothers dying per 100,000 live births, North Carolina ranks 37th in the nation for maternal mortality. In comparison, Maine, the top-ranked state, has 1.2 mothers dying for every 100,000 live births.

The reasons for the disparity are manifold, but major culprits include lack of health insurance, lack of access, and lack of education and awareness.

Nevertheless, lawmakers in Raleigh have already made significant cuts to the Baby Love program, which provides nursing and social work to low-income women. They are considering doing away with the program altogether — an idea that causes deep worry for health officials across the state.

“We’re not sure where these clients will go if that program ceases to exist,” said Debbie Sprouse, adult health supervisor in Haywood County.

Logical disconnects

Julie Guffey, a 28-year-old Waynesville resident, says she can’t fathom why those who need prenatal care aren’t receiving it. Guffey qualified for Medicaid for Pregnant Women when she gave birth to twin girls almost a decade ago and easily obtained it again after learning she was pregnant late last year.

Medicaid for Pregnant Women covers all pregnancy-related costs, even those that result from complications. It also provides one year of Medicaid coverage for the newborn child automatically.

Guffey says the entire application process is very simple, and the care she’s received has been excellent. Nurses have sent her home with thick educational packets to prepare her again for pregnancy, and she’s taken advantage of free birthing classes at Haywood Regional Medical Center in the past.

“If the services are available, and if you qualify for Medicaid, I don’t see why they don’t use it,” said Guffey. “Anyone who’s not getting prenatal care, it’s their own fault.”

It is relatively easy for low-income women to receive Medicaid for Pregnant Women, commonly called “Pink” Medicaid because its ID card had been pink at one point.

Income requirements are significantly more relaxed than those that exist for regular Medicaid.

For example, a family of four must make no more than $594 each month to qualify for Medicaid for families, while they can qualify for Pink Medicaid if they make up to $3,400 each month. Unborn children are included in the family count.

But even such a generous eligibility requirement can leave those who need financial aid floundering. Pregnancies in Western North Carolina can run up bills from $4,000 to $8,000. Ultrasounds cost $500 and up, and most women need at least two per pregnancy.

Having health insurance doesn’t necessarily shelter expecting mothers from the burden of financial worries. It’s not uncommon for policies to exclude prenatal care and to consider pregnancy a pre-existing condition.

Katie Martin, a 35-year-old Waynesville mother of two, said she paid nearly $2,500 in pregnancy-related costs, despite having state health insurance.

Martin says she’s not sure many of her friends could meet the Medicaid cutoff requirement even though they’d struggle to pay for prenatal care.

Because her own pregnancy was completely normal and she didn’t take any drugs during delivery, Martin was shocked when she set her eyes on such steep bills.

“I can’t even imagine if we had issues, how expensive the delivery would be,” Martin said.

Some of her bills had to be paid upfront, but Martin was able to set up a payment plan for the rest.

“Her birth is paid for now,” said Martin of her 1-year-old daughter, laughing. Of course, countless other expenses have piled up since then.

“From conception on, they cost a whole lot more than you would think,” Martin said.

Countless barriers to care

Charlene Carswell, prenatal clinic coordinator, understands that no matter how much she and her co-workers preach, some women will always insist that they don’t need prenatal care.

They’ll say “My sister didn’t have a low birth weight baby, and she smoked a pack a day,” said Carswell.

Others adamantly argue that no one received prenatal care a hundred years ago, so there’s no need for it now.

But late or no prenatal care can be detrimental to both the mother and the baby. It can lead to preterm births, dangerously low birth weights, gestational diabetes, and babies that haven’t fully developed.

Many of the women who don’t receive prenatal care do not have health insurance. Even those who have Medicaid may have trouble tracking down doctors who accept it.

Women who can’t afford medical care often put off early prenatal care to save up for the costs that’ll greet them in the third trimester. They pick and choose which tests they’ll get done and which they’ll skip. Even though it’s recommended that pregnant women get a check-up at least once a month, they’ll pass on those as well.

“They say ‘If I’m going to have to pay for the delivery, I’ll save for the delivery, not monthly visits to doctors,’” said Tania Connaughton-Espino, Latina program manager for the North Carolina Healthy Start Foundation, a nonprofit devoted to reducing infant death and illness.

Since Pink Medicaid applications can take up to 45 days to be approved, some patients who qualify for the aid skip out on appointments until it is formally approved.

Other barriers include lack of access to treatment, whether it’s not owning a car to drive to the health department or not being able to take off from work to make an appointment. Mothers might also not be able to line up childcare for their other kids while they are visiting the doctor.

And sometimes, it can be hard to even get an appointment with the recession sending waves of newly uninsured people to local health departments.

According to Connaughton-Espino’s experience, some women just might not see why prenatal care is necessary. They wonder why they’ve given up several hours of work time to wait for a 15 minute appointment with a nurse who measures their belly and takes their temperature.

“We just need to makes sure that moms understand that they can make that appointment important for them and ask questions,” said Connaughton-Espino.

According to Connaughton-Espino, the best route to a solution is through education. Some expecting mothers just don’t know when they’re supposed to take a prenatal vitamin or how often they should visit the doctor.

A whole other category of women who are not receiving prenatal care are undocumented workers. Because citizenship is a requirement for Pink Medicaid, illegal immigrants who are expecting often are left behind.

They do have the option of applying for presumptive eligibility Medicaid, which provides care until an application is formally approved or denied. However, this kind of Medicaid promises only a maximum of two months of care. It allows only minimal contact with a doctor and does not cover the cost of delivery.

At most public health departments, undocumented workers pay on a sliding scale based on their income. Even though the cost of care might be within reach, undocumented immigrants are afraid to even show up on the health department’s doorstep.

“They fear that they’re going to be arrested or shipped back to Mexico,” said Adrienne Maurin, a licensed therapist at Jackson County’s health department.

“Some of them come in later for care, some decline testing doctors recommend,” said McLaughlin, who tries to schedule ultrasounds and any other major tests within the few weeks that undocumented workers gets Medicaid coverage.

Children of undocumented workers who are born in the U.S. automatically get American citizenship, but they might still receive inadequate care because of their mother’s illegal status.

Carswell doesn’t think that that’s fair.

“It’s not the baby’s fault, whoever is pregnant,” said Carswell. “You just have to have good prenatal care.”

For many low-income women, pregnancy can lead to more stress than excitement. Most of the expecting mothers who visit local health departments are facing unplanned pregnancies.

Maternal care coordinators across the state have experienced firsthand all possible emotions along with the patients they support.

“I have a box of Kleenex in my office that I just leave here,” said Courtney McLaughlin, maternal care coordinator for Jackson County.

As part of the Baby Love program, maternal care coordinators contact patients once a month to check in throughout the pregnancy and up to two months after the mom delivers.

“Nine times out of 10, you’re their support system,” said Vicki James, maternal care coordinator for Haywood County. “You talk to them just like you do your own kid.”

Often times the father of the baby isn’t involved or the parents have turned their back on their pregnant daughter. So James picks up the slack and provides advice like a mother would.

She advises women on where to buy cribs, tells them how often they should see their doctor, and answers questions about what is or isn’t normal during a pregnancy.

James has made a lot of friends through her work, but the job comes with many ups and downs.

“It’s very rewarding, it’s very frustrating,” said James.

Jackson County, one of the few counties in the area to have a high-risk prenatal clinic, routinely sees extreme social work cases. Some expecting mothers are dealing with weighty issues, like sexual and physical abuse.

“You don’t know until you make a home visit what this pregnant girl is going through,” said Charlene Carswell, prenatal clinic coordinator for Haywood County.

Adrienne Maurin, a licensed therapist at Jackson’s health department, said she’s recently treated a pregnant woman who was just recovering from a substance abuse problem while simultaneously battling a mental illness.

Others have no psychological issues but come to Maurin just to vent their frustrations.

“They say, ‘I’m pregnant, and I don’t have a job, and I can’t get a job because I’m pregnant,’” said Maurin. “That causes a lot of stress for most of the ladies.

Of course, not all women who visit the health department have unhappy endings to their stories.

Carswell recalled a teenager who was petrified about her mother discovering that she was pregnant.

“Several of us cried with her,” said Carswell. “She was in a state.”

But when her mother found out, she was supportive, and to top it off, the baby’s father re-entered the picture.

James remembered one Hispanic woman who prepared a generous meal for her when she paid a visit, even though the woman had little to feed her own family.

“We had already ate, but we ate again,” said James, who was touched by the kind gesture.

James has seen women from all backgrounds, education and income levels and says there’s no stereotype for the kind of woman who takes advantage of the health department’s services, especially since the economic downturn.

Many who come in are finding it difficult to purchase basic baby supplies, like diapers, carseats and cribs — none of which is covered by Medicaid for Pregnant Women. Maternal care coordinators help provide some of those supplies, though their resources are quickly drying up.

“I’ve seen moms who have slept a baby in a laundry basket or a drawer,” said McLaughlin. Others share a bed with their baby, sometimes leading to cases of suffocation.

Maurin said she worries about her patients quite a bit, especially about the risks of post-partem depression.

“They are more prone to it because of the level of poverty,” said Maurin.