Images of Appalachia

The theme of this issue of Preventing Chronic Disease (PCD) — Appalachia — will stir a collage of images in readers' minds. A dominant image is likely to be derived from the great Appalachian mountain chain of eastern North America. A saddle gap in the top ridge of that mountain chain may yield a glimpse of a meandering river whose banks are covered with pastures and small towns where friends and family make their own traditional music. Another image may be of the great oaks, strong hickories, and straight tulip poplars of the mountainside. Along seeps and creeks, the shadow cast by an overarching canopy of hemlock boughs provides relaxation and restoration to a wayfaring hiker. The natural features of mountain ridges, forests, and riverbanks are the basic elements of many images of Appalachian cities, townships, and boroughs. In the bends of great rivers, an Appalachian city might be dominated by a steel mill or paper plant. Dairy and beef farms create a pastoral landscape in Appalachia's townships and counties. Coal mines in the Appalachian mountainsides have been the livelihood of many families for generations. Another dominant image of Appalachia is that of tight-knit communities composed of self-reliant residents with a distinct cultural heritage. Faced with limited economic opportunities and, for some, pervasive poverty, Appalachian communities remain vibrant. The Appalachian community itself may be a substantial source of its residents' strength. Although the recent disasters in the coal mines of Appalachian Kentucky, Pennsylvania, and West Virginia have been devastating and tragic, they have also given America front-page images of residents rallying around lifetime members of the community, ringing bells from church steeples for breaking news, and offering camaraderie both above and below the ground. To epidemiologists and public health researchers, the predominant images of Appalachia are those of increased chronic disease burden, limited access to health care, and elevated rates of behavioral risks. Surveillance data collected over decades show that this image is generally correct. Among whites in Appalachia, coronary heart disease mortality increased from 1980 to 1993 (1). Lung, colorectal, and cervical cancer mortality (2) and incidence (3) were found to be elevated in Appalachia. Residents of Appalachia have increased behavioral risks (4). The National Cancer Institute confirmed that mortality rates from cervical cancer were especially high in Appalachia and concluded that cervical cancer mortality is a marker for larger health system concerns, including medical care access, cultural issues, …