Granny tried to put on a brave face when I asked her about it. I wasn’t quite sure what to say, how to politely ask about being diagnosed with advanced lung cancer. Granny smiled and gave a laugh: “It’ll take more than a little spot on my lungs to git your old Granny, don’t you know it?” But I could see her lip quivering slightly. Her thick glasses magnified the extra moisture welling in her eyes. I knew that she was afraid. I was too.
The family—my parents, Ruth, Dale—encouraged Granny to come and stay with us in Berea while she got treatment. There was no place for her to get the radiation she needed in Owsley County. Things had come a long way over the years; there were now a couple of doctors who practiced in Booneville. But the type of specialized medical care Granny needed was not available in her mountain holler. And Granny had no way of driving herself to any out-of-town doctor’s appointments. She never did get a license, and if there were programs to provide her with transportation to travel such a long distance on such a regular basis, she never heard of them.
Granny’s situation mirrors that of Appalachia as a whole. Even today, the supply of primary care physicians is 12 percent lower in Appalachia than in the rest of the United States. This disparity is even greater for specialty care, at 28 percent. Focus in on rural Appalachia, and the supply of primary care physicians is 20 percent lower than in urban Appalachian areas, and the supply of specialists is 57 percent lower. Finding a doctor, particularly a specialist, is hard in Granny’s part of the country.
That’s why we were all thrilled to find out that a hospital in Berea had just purchased the type of technology Granny needed. My mother had flexibility in her insurance job, and she would be able to drive Granny to and from her doctor’s appointments. It made sense that Granny would come and stay with us.
It made sense, that is, to everyone but Granny.
Granny let us all know that she didn’t like the idea. “Lord, y’all just expect me to up and leave my home?” she protested, her voice shrill and alarmed. Home was everything to Granny. After Aunt Ruth married Sonny, Granny had moved to a semi–assisted living facility close to Booneville. She had a small apartment with new appliances and good lighting. It was a world above the falling-in particleboard trailer she had lived in for so many years. Although the facility didn’t have the resources to drive her all the way to Berea for doctor’s appointments, it could take her places like the local pharmacy and grocery store.
But most important, Granny had made friends. Her facility had a community room that she could walk to in the afternoons. A local preacher came a couple of times a week to hold a church service there. There were sometimes group activities or holiday celebrations. Granny took up crafting. It was the least isolated she had ever been. She had spent years living in a holler with no transportation, seeing her friends sporadically, if at all. Now she was steps away from company and companionship.
Granny embraced her new community and its members. Even when she was sick—on around-the-clock oxygen—she would drag her tank next door to help her friend Opsie wash her hair. She would weed her neighbor Claire’s flower bed, scooting around on a board with wheels when she was too weak to stand. She swept her tiny apartment every day—often sitting in a chair—to make sure she was always ready for company.
There was something beautiful about this community full of aging mountain women. They had spent their lives surrounded by children and family, but perhaps lonely for friendship. Now they finally had a chance to sit, rest, talk. Many of them hadn’t had time to visit with one another since they were children together so many decades before. It’s no wonder Granny didn’t want to leave.
As a compromise, my mother drove Granny back and forth from Berea to Owsley County a few times a week. The first day or so Granny was in Berea she would be happy to see us, telling us all about the goings-on in Booneville. “They killed Boogerman Peters!” she told us in horror. Strange nicknames were common in Owsley County; I know a Froggie, a PloughBoy, and a Digger. But this name sounded stranger than normal. When I asked her how this man—tragically murdered—had come to earn his title, she looked at me pensively. “Well, I suppose he kind of looked like a Boogerman,” she replied after a few moments. I wasn’t sure if I was supposed to laugh.
Inevitably, though, Granny wanted to go home. After being in Berea for a few days, she would come to my mother and beg, “Please, Wilma. I want to go home. Take me home.” My mother would try to persuade Granny otherwise. Granny was getting sicker, her body weakened by the cancer and the treatment, and we were starting to worry about her living on her own. She had to drag her oxygen tank with her everywhere she went. But my mother was no match for Granny’s persistence. Eventually we would load up the car and drive to Owsley County.
I sometimes think about all the iterations of women in my family who have traveled the curved road from Owsley County to Berea and back. From Wilma that first time on her way to college, to Granny and Wilma driving Granny back to the comfort of the mountains all those years later. That first journey opened up the path to Berea, but this didn’t make it the destination for every woman who traveled it. Berea would never be home for Granny, nor for Ruth. In the same way, the road back to Owsley County was always open to Wilma. Yet it was never again her way home.
* * *
—
I wish I could say that having Granny with us more was always a joy, that I responded to the change in my teenage life with nothing but kindness and understanding. But this would be a lie.
There were times when it was wonderful, like when we went to the London flea market and Granny bought me my first Ralph Stanley cassette tape. We listened to it all the way home, my mother and I singing at the tops of our lungs. Granny sang too, her voice as loud and joyful as her weakened lungs would permit. My mother took us through a KFC drive-through, and we embarrassed her no end by cranking up the bluegrass music and dancing vigorously as the restaurant worker handed us our bucket of chicken. I can still picture Granny, too weak to move much, rolling her fists rapidly to the music, like a boxer hitting a teeny-tiny punching bag.
There was also the time Granny went to a bookstore with my mother and me. My mother was looking for some sort of professional book, and she left Granny and me to our own devices. Granny and I grabbed a cart and filled it with the most lustful-looking romance novels we could find. We brought the cart to my mother and asked her to buy its contents for us. My mother turned a bright red and exclaimed, “Good night! You two are trouble.” Granny and I laughed all the way home. The next year for Christmas, Granny got me a romance novel.
Granny reminded us of the importance of family, of spending time with one another. One evening, my father wanted to watch a University of Kentucky basketball game in the living room. My mother, uninterested in sports, tried to convince Granny to go and watch a movie with her in a different room. Granny, a serious look in her eye, scolded her, “Orlando has been at work all day. I’m goin’ to sit right here and spend time with him. I reckon you best do the same.” Granny and Wilma joined Orlando to watch the game. Granny didn’t know anything about basketball, but she cheered enthusiastically. It was a particularly physical game; at one point she jumped from her seat and shouted with venom, “You ain’t nothin’ but a big bully—take your tail end home!” My parents looked at each other in shock.
Granny also remained incredibly generous, just as she always had been. She survived off of nothing more than the small Social Security check she received each month, but she shared what little she did have. She took homegrown tomatoes to her pulmonary doctor’s office because he had once mentioned that he liked them.
I, in particular, was the beneficiary of Granny’s generosity. Granny always had a soft spot for her grandchildren, and she and I had a special bond. We both loved music, loved to dance. We liked getting out of the house, even if it was just to drive through town to see if we met anyone we knew.
When I was in h
igh school, I started to learn how to play the guitar. Granny insisted on buying my first instrument. She would joyfully listen to me bobble chords, hearing the familiar songs I hadn’t quite been able to bring into being yet. She would clap her hands to the errant beat, humming along to the twisted melody.
As my skills improved, Granny continued to buy me guitars. Every so often, when I was in Owsley County, she would ask me to come into her bedroom, claiming she needed my help with something. She would press a finger to her lips before reaching under her mattress, into a coat, or inside an old purse to pull out a couple of hundred-dollar bills. Granny didn’t trust banks, and it was always interesting to see where she was hiding her money in any given week. She would whisper into my ear, “Go on and git you a new git-tar with this,” before loudly asking me to help her move a chair from her bedroom to the living room. She knew my mother would scold us both if she caught Granny giving me so much money.
Granny got joy out of these gifts she could not afford to give. She had medical expenses, a fixed income. She must’ve been worried about having enough money to live on. Still, she gladly set aside large sums to buy me an instrument. All she asked in return was that I occasionally play a song for her.
I loved Granny. Full stop. No exceptions. But I am ashamed now that there were also times when I felt embarrassed by her. By her heavy accent and slow speech. By her unfailing, sometimes childlike, happiness. By her simplicity.
Once, when she was very sick, she came to one of my soccer games. She and my mother set up folding chairs on the sideline with the other families. Granny spent the game yelling “Yay, Cassie!” each time I ran past her. Her fists were in the air and her eyes were sparkling. She was so joyful, watching her granddaughter play a mediocre soccer game. But I didn’t relish her joy: I wanted her to be quiet. Her accent stood out and cut through the rest of the cheers. She had never been to a soccer game before, and she kept hollering at all the wrong times. At the end of the game, I intentionally walked off of the field in a direction that let me avoid saying hello.
I was becoming aware of the ways in which parts of my family were different. Different from the families on television. Different from the people in New York. Different, even, from many of the people in Berea.
I had always known the word hillbilly. I had heard Sonny, Dale, and Ruth use it often to describe themselves. “I’m just an old hillbilly—what do I know?” Dale would sometimes add after offering his opinion on something.
I understood that the word applied to people like Granny, my mother, maybe me. But I hadn’t always known that I should be ashamed to be a hillbilly. I hadn’t realized the way the rest of the world used that label as a brand. As a way to mark the inferiority of the people who live in the hills. As shorthand for all of the negative things the outside world thought about us: ignorant, lazy, unsophisticated.
I knew people who embodied some pieces of the hillbilly stereotype. Kin and acquaintances who didn’t work, didn’t travel, didn’t trust the outside world. I have one distant cousin who had never left the state of Kentucky until a few years ago. One day, he went to Ohio for work, and called his mother from a friend’s cellphone as he crossed the state line. “Mommy?” he said. “This is Elmer. This here O-hi-o looks like someone ironed out the land!” When I heard this story, I recognized that the rest of the world would laugh at him for fitting so easily into their idea of what a hillbilly is.
Even back then, I understood that hill people were more complex than the outside world believed. My family members were hardworking, quick-witted, and creative. The hill women I knew were strong and powerful. But still, the hillbilly label weighed heavily on me. One day at school, one of my friends declared that we couldn’t be friends with the new girl in our class because she was “nothing but a redneck hillbilly.” I was too worried that the group would sniff out my own hillbilly roots to say anything in the girl’s defense.
Over the years, I’ve seen many strong mountain people take the hillbilly label and wear it proudly. As one of my friends told me, “I don’t mind being called a hillbilly. Hillbilly is a culture, the culture of the mountain people. But Lord, don’t call me a redneck. You can be a redneck anywhere. You can only be a hillbilly in these mountains.” My opinion on the term has evolved somewhat, and sometimes I feel proud to wear the hillbilly label. But I remember what it was like, as a teenager, to lie in my bed at night and worry that I was a hillbilly; to worry that hillbilly was all the world would see when they looked at me.
* * *
—
While Granny was getting her treatments, Aunt Ruth was dealing with breast cancer. She’d been diagnosed for the first time shortly after marrying Sonny. I don’t remember much about her reaction, probably because she kept whatever reaction she had very private. She didn’t believe that wallowing in emotion made things better. I’m sure she put on a stoic face.
After two surgeries and a round of radiation therapy, the doctor announced that Ruth’s breast cancer was in remission. I stayed with her for a few days after one of her surgeries. Not because she needed the help—it never crossed my mind that I had the capacity to help Aunt Ruth—but because I was worried about her. I wanted to see her and make sure she was okay.
She was changing her dressings when I arrived, removing the bandages that covered her incisions. When she saw me standing in the hallway, she asked me to help her. I remember Ruth’s no-nonsense tone about the whole thing. She wasn’t embarrassed to show me her scars, the changes to her body. She told me how to remove the bandages in a matter-of-fact way, like a teacher walking a student through a math problem. Afterward, we went and made a banana pudding for a picnic the next day. It was as if nothing unusual had happened.
Now, a few years later, Aunt Ruth’s breast cancer was back, on the other side. Once again, she bravely faced surgery and radiation. Even though the radiation left her bones brittle and aching, she didn’t complain. I can remember her saying “Lord a night, that radiation has me feelin’ like I’m on fire!” only once before she went back to her chores.
I didn’t realize at the time that bilateral breast cancer is uncommon; only a little more than 1 percent of all women with breast carcinomas have a bilateral occurrence. At the time, I thought that maybe it was just bad luck—maybe Aunt Ruth was just the one out of every hundred women who got unlucky.
Now I’m not so sure.
The health disparities in Appalachia are well documented. A comprehensive 2017 report on the state of physical and mental health in Appalachia found that this region performed worse than the national average on thirty-three out of forty-one indicators. This includes higher rates of heart disease, cancer, COPD, suicide, diabetes, injury, and stroke. It also includes more physically and mentally unhealthy days, and a greater prevalence of depression. The things that Appalachia scores better than the national average on include commute time to work, excessive drinking, and student–teacher ratio. I think most people would gladly trade the shorter commute for a lower cancer rate.
Researchers understand some of the reasons why Appalachia is less healthy than the rest of the country. For one, data shows that people from there engage in more unhealthy behaviors. Nearly one-third of Appalachians living in rural counties report being inactive, and almost a quarter are smokers. Both of these activities dramatically increase morbidity and mortality.
It’s easy to blame these individuals for their poor choices. For a long time I did. I blamed Granny for starting to smoke, and other relatives for letting their weight get out of hand. I still get frustrated with one distant cousin, aged eighteen, who is so large that he struggles to sit or stand on his own. It seems so simple in abstraction: Why can’t people just make healthier choices?
But I also know firsthand how hard it is to make healthy choices in Owsley County. I am a runner. I don’t run fast, but most days of the week I put on my sneakers and I hit whatever road I happen to find nearb
y. I’ve found ways to run on almost every trip I’ve gone on: Berlin, Vietnam, New York City.
But when I am in Owsley County, I don’t run. The roads are too narrow, and I’m worried about getting hit by a car on the snaking curves. I don’t have cellphone service to help me navigate home if I get lost. It’s unusual to see someone jogging, and I’ll admit that I am self-conscious about attracting attention. I know that if I go for a run, people will talk about it. A couple of decades ago, a woman opened an aerobics studio, and the town gossip mill churned out rumors of women “hopping around in their undy-wear in front of God and everyone!” Today there are no gyms other than the one at the school.
It’s also hard to find healthy food in Owsley County. The produce is limited and expensive. The best selection is at the Dollar General, which isn’t exactly known for the quality of its vegetables. I am someone who eats salads on a regular basis. I have never eaten a salad in Owsley County.
I say all of this not to let people completely off the hook for their unhealthy decisions. It’s not as if Appalachians are so unsophisticated and irrational that they are incapable of making good choices. People in the mountains have agency, and they use it. But environment and culture are powerful things, and they exert their influence over individuals in a complicated way. I am a person who defines myself by my healthy choices. And even I fall into a pattern of unhealthy behavior when I am in the mountains. You might as well.
But these differences in behavior don’t fully account for the health disparities in Appalachia. Even when models adjust for things like the increased rates of smoking and unhealthy eating, disease rates are still higher than expected. What accounts for this difference?
The answer, I think, is environmental health hazards. There are a lot of unique and dangerous pollutants in Appalachia. Coal mining through mountaintop removal releases toxins like lead and arsenic into the streams and groundwater. The explosives used to remove parts of the mountain can launch toxic dust into the air, and this dust later settles back into the environment. Tobacco farming, too, carries health risks. Tobacco is an insect-prone crop, and those who farm it need to apply pesticides frequently and generously. Pesticides can harm farmers both through direct contact with the skin and through agrochemical contamination in the soil and water supply.
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