Perry County, AL, with a population of 9140, is not unlike many rural communities in the southern United States. But with a poor population and a severe lack of access to medical care, residents of the county face seemingly insurmountable hurdles to receiving healthcare, and this is particularly exacerbated for patients with cancer. However, according to Frances Ford, RN, who has served the community of Perry County for more than 20 years in her capacity as the Perry County health coordinator and executive director of Sowing Seeds of Hope, a local nonprofit, tackling these barriers to care can be done, but it takes education and screening, strong partnerships, and a lot of hard work.
About Perry County, AL
This county is poor and lacks adequate public transportation and infrastructure. Most roads are made up of 2 lanes and are badly in need of repair. Its system of “public transport” is made up of one 15-passenger van, available to transport people without access to private transportation to medical appointments. “Most of our 9000 people are using this 1 van as public transportation,” she said. “It makes trips upon request, and it has to serve the entire county.” Perry County also only has 1 grocery store, and it has the least broadband coverage in the state of Alabama.
Ninety-three percent of eligible individuals are employed in Perry County, but 33% of employed individuals still fall below the poverty line due to the lack of living-wage jobs in the community. Half of all households are female-headed, and 70% of female-headed households live below the poverty line. The community is predominantly black (68%), with a white population of 30%, and 2% “other.” The overall poverty rate is 37.2%, among African Americans it is 48.9%, and among children it is 51.3%. “Over half of our children live in poverty,” she noted. The vast majority of the population is generally considered “working poor,” with a median household income of $26,703.
Chronic diseases represent a serious risk to the health of Perry County residents. According to the Robert Wood Johnson Foundation’s County Health Rankings & Roadmaps, Perry County ranks 64th out of 67 counties for length of life, 66th of 67 for health outcomes, and last in the state (67th of 67) for overall quality of life.
The availability of primary care treatment exists in the county, but is extremely limited and made up of a patchwork of state, local, private, and nonprofit providers to meet the needs of the community. The largest medical center in the county has 1 doctor and 1 nurse practitioner, the 2 rural health centers have 1 doctor and 1 nurse each, and the Perry County Health Department lacks even 1 doctor. There is a mental health center, a dialysis center, a pharmacy, and 2 nursing homes in the county.
Perry County has not had a hospital since 1999. “This is what I mean when I say there’s a lack of access to care,” she noted. The distance to the nearest hospital is 30 miles, and there are only 2 ambulances serving all 9000 individuals in the community. The distance to the nearest oncology treatment is 60 miles, and regular specialty care does not exist.
The prevalence of diabetes and cardiovascular disease is high in Perry County. Approximately 20% of the population are diabetic, and 35% of deaths in the county are from some form of cardiovascular disease. Ms Ford stated that “chronic disease and general poor health in the community makes cancer treatment more difficult” by limiting treatment options, creating additional risk factors and adding to the number of possible conditions needing treatment.
Addressing Cancer in Perry County
Perry County illustrates well the challenges in reaching the underserved and underinsured populations of many rural counties, but these challenges are particularly acute when addressing the cancer population. According to the Alabama Department of Public Health, Perry County has the following cancer prevalence rates: 212 per 100,000 for prostate cancer, 128 per 100,000 for breast cancer, 75 per 100,000 for lung cancer, and 49 per 100,000 for colorectal cancer, but cases are frequently undercounted in rural areas due to a lack of screening availability.
In addition to a lack of access to cancer screening, other major challenges facing patients with cancer in these rural communities include people’s lack of knowledge of the warning signs of cancer, the disease process, and treatment options; a lack of adequate insurance coverage and no real ability to pay; and a lack of access to local treatment options (compounded by a lack of access to transportation to treatment centers in other areas). The resultant delays in diagnosis and treatment negatively impact patient outcomes and increase cancer morbidity and mortality rates.
The Importance of Collaboration
Ms Ford has spent more than 20 years in the county working to mitigate these barriers to adequate treatment for her clients. “Collaboration with larger health systems, community-based groups, and local healthcare providers is critical to addressing the lack of health access in rural communities,” she said.
Sowing Seeds of Hope has partnered with healthcare organizations and providers from larger cities in Alabama to provide health screenings and educational programs to the citizens of Perry County at no cost. These include initiatives to address breast cancer and prostate cancer, as well as a number of other chronic diseases. “We’re doing what we can to help; we don’t have specialty care here, but we do what we can to bring those services into the community,” she said. “Our experience is that these services are well utilized by our community members, and they’re well received.” These outside resources provide much-needed screenings and proper referrals, as well as materials related to a variety of medical issues. In addition, they assist with helping people to understand and access the Medicaid system in the state.
According to Ms Ford, another key component to breaking down barriers and assisting the community of Perry County is education. “We educate the community and make sure they are aware of the services available to them, where those resources are, and the criteria for those services,” she said. “Instead of being reactive in rural communities, we need to be proactive.” This includes utilization of churches for the dissemination of information, community health workers working in the community, face-to-face meetings, and information disseminated on local radio stations and social media.
“If you live in a rural area, be the voice for your community; be the advocate for your community,” she stressed. “Encourage people to be screened, and help them with transportation. If there is a negative report, be there for them and listen to them. People don’t always need all the answers; sometimes they just want someone to listen.”
The continuing efforts of people like Ms Ford and her staff to develop sustainable processes to ensure delivery of high-quality medical care to this underserved population is both challenging and vital to public health.
“Because we don’t have access to as many facilities and providers, these efforts require that we partner with larger organizations,” she said. “We’ve been working for the last 20 years to make a difference. As we identify problems, we seek opportunities to solve them. And if we can’t solve them, we find ways to address them.”