Rural Cancer Disparities
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Cancer death rates in Appalachia are among the highest in the nation.

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In areas like Appalachia, the disease hits particularly hard.

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By Sue Rochman

The Culture and Cancer of Rural Poverty

Nowhere in America is the connection between rural poverty and cancer as clear-cut as in Appalachia

By Sue Rochman


Photographs by Charles Bertram


When Bruce Behringer gave a presentation on cancer last year, he began by telling a story. It started with the number 44.

A road in Appalachia“This,” the cancer researcher said, “was our state’s ranking in cancer incidence from 2000 to 2004.” Behringer, who is the executive director of the Office of Rural and Community Health and Community Partnerships at East Tennessee State University in Johnson City, then showed the number 20. “And this,” he said, “is where we were in 2005.”

But just as Behringer’s audience began to consider this dramatic jump in the state’s cancer diagnosis ranking, an even more alarming number appeared in his next Powerpoint slide: six. “This,” he intoned, “was our state’s ranking in cancer mortality from 2000 to 2004.”

Finally, Behringer showed the number three. “Folks,” he said, “this is not the University of Tennessee’s football ranking. And it’s not the Lady Vols’ rank in basketball. We were No. 3 in the country in cancer mortality in 2005. And that’s not where we want to be.”

Behringer and other experts on rural cancer disparities can rattle off dispiriting statistics with ease: poverty rates; unemployment rates; the number of hospitals or physicians in a region. But, they are quick to point out, these figures can only partially explain the low cancer-screening rates and late-stage diagnoses—and the correspondingly high cancer death rates—that are emblematic of rural regions. Less quantifiable, but no less significant, they note, is the culture of rural poverty and the inroads it provides to cancer cells.

And in the United States, there are few areas that demonstrate as clearly as the Appalachian region the extent of this problem—and what is required to overcome it.


The Appalachian Region
Appalachia is a 205,000-square-mile area that is home to 24.8 million people, of whom 42 percent are rural residents (compared with 20 percent of the U.S. population). The region begins in southern New York state and ends in northern Mississippi. Spanning 420 counties and crossing 13 states, it incorporates all of West Virginia, and includes parts of Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee and Virginia.

To geographers, Appalachia is distinguished by the mountain range that runs through the region. To epidemiologists, it is a hotbed of cancer. Six of the seven U.S. states with the highest cancer death rates are part of Appalachia, and most of the other Appalachian states are not far behind. (Since Behringer gave his presentation last year, Tennessee’s ranking dropped slightly from 3rd to 5th.)

People in Appalachia aren’t unconcerned about cancer. They know the stories of the people behind the statistics, and many are downright scared that they, too, will be given a cancer diagnosis. But for many, the area’s pervasive and persistent poverty means concerns about cancer are almost a privilege. This year, the Appalachian Regional Commission, a federally funded economic development agency, categorized 82 of the region’s 420 counties as economically “distressed” because they ranked in the worst 10 percent of the nation’s counties on three economic indicators: three-year average unemployment rate, per capita market income, and poverty rate. Another 79 counties were labeled “at risk.”



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