Ludke says Appalachian inhabitants from coal-producing regions, for example, would feel the ill effects of living in a contaminated environment, just as any urban inhabitant might suffer from living near an industrial complex, or from moldy and substandard housing.
There are lifestyle behaviors, particularly around high-fat diets and high incidences of tobacco use in Appalachia and among lower-income Americans regardless of their neighborhoods that contribute to health problems.
There is a high incidence of mental illness and substance abuse. Finally, there is the poverty—the grinding, stubborn and notorious pockets of blight that can be found in the shadows of mountains and sky scrapers.
"When you put together the environment, the lifestyle behaviors, the socio-economic status, and couple that with this overlay of the healthcare system and the difficulty to access services because of where they are located, they all contribute to the greater disparities," Ludke says.
He was talking specifically about Appalachia, but the words could apply to the health issues that are seen every day at urban safety net hospitals.