The Stroke Belt

Coming Sunday: On the Mexico border, some of the state's longest life spans. 

The proof of Anderson County’s live-hard, die-young culture is in the bread pudding — and the all-you-can-eat fried catfish, the drive-through tobacco barns and the doughnut shops by the dozen that dot this small East Texas county of about 57,000 people.  

In a community where heavy eating and chain smoking are a way of life, where poverty, hard-headedness and even suspicion hinder access to basic health care, residents die at an average age of 73 — seven years earlier than the longest-living Texans, according to a preliminary county-by-county analysis by the University of Washington Institute for Health Metrics and Evaluation. Black males live to be just 65. And white men outlive black men by roughly six years, one of the largest disparities by race in the state. Indeed, life expectancy lags across most of East Texas, which lives up to its grim medical moniker: “The Stroke Belt.”

The early deaths are the result of sky-high rates of obesity, diabetes, cardiovascular disease and cancers, afflictions directly linked to lifestyle choices, including poor diet and smoking. Anderson County’s hospitalizations for preventable conditions like congestive heart failure, high blood pressure and adult asthma far outpace the state average.

Such maladies are tied firmly to race and poverty. East Texas has top-notch health care facilities for those with the money and insurance to access them, including the region’s growing number of snowbird retirees. For the impoverished, predominantly minority residents without medical insurance, transportation or trust in the health care system, life takes another path entirely.

“I feel like life does get cut short,” said Michael Bolton, a 47-year-old African-American with perilously high blood pressure whose own father died of a heart attack at 49. “I’ve lost a lot of people I grew up with. I didn’t even think they were sick.” 

Battered and buttered

It is lunchtime in Palestine, the county seat, and the D.J. on 106.5 FM is not letting listeners forget it. “Caller Mary Beth is the winner of a free dinner from Texas Roadhouse!” he croons. “Her favorite is steak and potatoes and chili!” At a local diner, a chalkboard menu advertises dishes “deep fried” and “battered” and “buttered,” and waistlines are wide, even on small children. “Y’all want dessert?” a waitress refilling sweet teas asks customers, her drawl as sugary as the cobbler she is serving up.

It is the Old South diet — the staple of every church picnic and backyard barbecue from Anderson County clear to Alabama. And it is a leading contributor to the uncontrolled high blood pressure, obesity and diabetes plaguing much of the region. Gyms often sit empty, day and night. The corner coffee shops are all Donut Palaces. In neighboring Cherokee County, the East Texas Medical Center Jacksonville hospital brochure features a recipe for Barbara’s Buttermilk Pie, with two cups of sugar and five eggs.

“It’s the old biscuits and gravy that sticks to the arteries,” said Connie Fiser, a nurse who runs the hospital’s intensive care unit and inpatient care center, and sees an endless stream of patients with complications from diabetes.

But it is not the only factor reducing East Texas’ life expectancy. Smoking rates and lung cancer deaths are higher here than across much of the state.  Roughly a quarter of the population here smokes, compared to 20 percent in the rest of the state. Jerry Walding, a white, 47-year-old oil field worker, has smoked for more than three decades, sometimes more than a pack a day. His father’s death by stroke at 72, his mother’s heart attack death at 65 and his half-brother’s fatal heart attack at 45 have done nothing to curb his habit, or to inspire him to see the doctor. “When the good lord says, ‘It’s time for you to go,’ it’s time for you to go,” Walding said. “It ain’t up to me or to nobody else.”  

History and hard-headedness

Health care experts hear this kind of fatalism all across East Texas. Despite the excellent hospitals and health care providers, preventative care remains the exception, not the rule. Locals do not go to the doctor unless they are “really, really sick,” said Steven R. Shelton, executive director of the East Texas Area Health Education Center. “And by then, they’re already far down the road.” 

In Anderson County’s African-American community, the more pronounced trait goes by a simple name: “hard-headedness.” Dr. Kirk A. Calhoun, president of the University of Texas Health Science Center at Tyler, said black men like himself hesitate to seek treatment. They see it as a sign of weakness, he said, or they fear what they might find out.

Mike Anderson, a 51-year-old Palestine charter school superintendent, said the hard-headedness has roots in segregation. In a still largely divided county, many black people do not believe that the health care system is there for them — it is on the other side of the metaphorical tracks.

“It’s not that there’s any sinister plan to keep anyone from getting health care,” he said. “I just think this history of mistrust, suspicion and cynicism may explain why there’s such a disproportionate life expectancy.”

Anderson County Judge Linda Ray’s response when asked about the life expectancy gap in her community seemed to reflect these divergent experiences. Ray, who is white and the county’s top elected official, mentioned a sparkling new cancer center and a couple of good primary care physicians in the county. Other than that, she said, she did not have an opinion on the matter. “I guess it doesn’t affect me enough,” she said, “fortunately.”  

Life and death on “the border”

It does affect people like Bolton. The gregarious 47-year-old still lives in the predominantly African-American neighborhood where he was born and raised. Despite his medical history — malignant hypertension, a hospitalization for chest pains, and his father’s fatal heart attack — he does not take blood pressure medication and cannot remember the last time he saw a doctor.

Bolton has a job — at a hospital parts manufacturer, no less. And he has health insurance. But he said the only local doctor in his network is not taking new patients. The others are an hour away in Tyler, and he has no transportation to get there. Nor can he afford the co-pays and prescriptions he knows come with a visit to the doctor. Bolton is not alone: in a recent East Texas community survey, residents overwhelmingly reported struggling to find dentists who accept Medicaid, outpatient mental health services or transportation to appointments.

“Am I nervous? I’m very nervous. I’ll be 48 this year, and my blood pressure’s 215 over something,” Bolton said. “Sometimes I feel the way my daddy used to feel. And he died real young.”

Dr. James Low, a Jacksonville primary care physician who has spent the last two decades practicing less than two miles from Bolton’s home, acknowledged this grim reality: The region’s few local physicians are swamped, and many are not taking new patients. Transportation can also be a hindrance; some of his patients walk from their homes to see him.

“We don’t ask what color they are; we’ve never limited our practice, but we don’t get a lot of minorities,” Low said. “And when we do get them, they’ve sometimes not made follow-up visits. They felt better after that visit, so why go back?”

Removing cultural barriers to care won’t happen overnight, despite Low’s tireless, but so far unsuccessful, efforts to pass a local smoking ordinance; Calhoun’s work at UT-Tyler to attract more nutritionists and health care providers to East Texas; and Anderson’s prodding to get students to eat better. And with ever-rising rates of obesity and diabetes, the barometer is moving in the wrong direction.

“Texans always assume the worst health disparities are along the border,” said Shelton, with the East Texas health education center. “They’re right — along the Texas-Louisiana border.”