Money doesn’t come easily to Polk County, Texas. If you take the Livingston exit off Highway 59, heading west on Highway 190, you’ll pass the town’s Walmart, one of area’s large employers.
Take a left on FM 350, and after about five miles of country road, you’ll arrive at the tall orange-and-white-checkered water tank that marks Allan B. Polunsky State Prison, home to Texas’ Death Row, and another major source of jobs. People in the county work in lumber, too.
It’s a different story 120 miles away, in Fort Bend County, a sprawling suburb of Houston. Large employers there include Schlumberger, an energy technology company; and Texas Instruments. Sugar Land, one of Texas’ fastest-growing cities, is there. City websites promote the place as both an economic powerhouse (“Sugar Land means business”) and a tourist destination (“Summer is sweeter in Sugar Land”).
The thing is, it’s not just harder to make a living in Polk County; life is shorter there, too. On average, residents of Polk County die almost a decade before those of Fort Bend.
“Inequalities of life expectancy between counties are getting larger and worse,” says Dr. Ali Mokdad, an epidemiologist at the University of Washington’s School of Public Health. Recently, in the journal JAMA Internal Medicine, Mokdad and colleagues published a county-level analysis of population and mortality data over the past 35 years.
What they found is both remarkable and alarming: What county you live may determine how long you’ll live.
Though U.S. life expectancy has increased in the past 35 years, the gains haven’t been evenly distributed. From 1980 to 2014, our national life expectancy increased from 74 to 79 years. But between U.S. counties, average life expectancy can differ by more than 20 years.
The longest lives tended to be in counties on the west coast, northeastern coast, Rocky Mountain regions and in Minnesota. Some counties in Colorado averaged 87 years in life expectancy.
The counties with the lowest life expectancy were mainly in the South, especially along the Mississippi River, and in the coal country of eastern Kentucky and western West Virginia. North and South Dakota also had poor results — particularly the counties that included Native American reservations. Some of the worse counties logged averages as low as 66 years.
In Polk County, people live to 73, on average. In Fort Bend County, it’s 82.
What explains this difference? “We found three general factors explained 74 percent of the disparity between counties,” says Dr. Mokdad. That amounts to behavioral/metabolic factors, socioeconomic factors — and the health care access of the places they live.
CLARK EVANS, 78, is a real-estate broker with white hair and wire-rimmed bifocals. He stays active by riding horses on his ranch, and at his home office there, Texas A&M memorabilia is scattered among framed photos of family and friends.
But I was visiting because, for the last 10 years, he’s been the mayor of Livingston. He’s lived in Polk County almost all his life.
His vice, he said, used to be smoking. But that was back when “everyone smoked,” and he quit 50 years ago.
“Life is about choices,” he said, and people should be allowed to make them.
“I don’t think to have the government’s hand in this is going to solve these problems,” he said when I asked about city ordinances or programs to promote healthy behavior. “We had these folks come from Lufkin promising us money for the city awhile back. But when the terms were on passing three city ordinances a year to do things like ban smoking in businesses and such, we said, forget it.”
“We don’t want to tell businesses what they can and can’t do when something is legal.”
Smoking is major health risk in Polk County. We know smoking is major contributor for developing cancers, especially lung cancer and cardiovascular disease. Data from 2014 show that the while the average Texas county had smoking rates of 17 percent, Polk County was much higher at 29 percent. This has had devastating effects: Out of 254 Texas counties, Polk had the second-highest death rate from lung cancer and the sixth-highest from cardiovascular disease.
But Fort Bend, with its affluent suburbanites, ranked as having some of Texas’ best health behaviors. Only 10 percent of its residents smoke. And its residents have lower obesity rates and are more physically active than those of most other counties.
In fact, many cities in Fort Bend have ordinances banning smoking. Since 2007, when Sugar Land outlawed smoking in parks, restaurants, public spaces and outdoor arenas, smoking has decreased by 16 percent. And death from cardiovascular disease and lung cancer has decreased by 15 percent and 21 percent.
It seems there are connections between public policy and health. We know laws can promote better health outcomes. Consider a study from the Mayo Clinic, in 2002, when Olmstead County, Minnesota, made restaurants smoke-free, and in 2007, all its workplaces. The change saved lives: Mayo Clinic researchers found a 33 percent decrease in heart attacks and a 17 percent drop in deaths from cardiac arrest.
But Polk County, with its poorer, more rural population, ranks in the bottom six percent of health behaviors. Residents also have higher obesity rates and are less physically active. All those behaviors can contribute to cardiovascular disease, diabetes and some cancers.
Between 2010 and 2014, Polk County residents had the highest age-adjusted rates of all cancers in Texas.
FIFTEEN MILES east of Livingston, east on Highway 190 but still in Polk County, is the Alabama Coushatta Tribe Reservation, home to more than 500 people.
Native Americans have one of the highest rates of Type 2 diabetes in the country, and about three years ago, the reservation’s health clinic used federal money to launch a wellness program. It offers Zumba and yoga classes, organizes community walks and pays nurses to make home visits to counsel tribe members on healthy eating and physical activity.
The program has been a success, says clinic director Myra Sylestine. As an example, she tells about a tribe member who seemed to eat nothing but fried food at home. When the visiting nurse asked why, the resident explained that she didn’t own an oven. The nurse helped her find one, and now she can bake and broil.
Such simple interventions, though, might be in jeopardy. The White House’s budget proposal suggests enormous cuts to the two agencies that fund the wellness program: Center from Disease Control, and to make many other cuts to the Department of Health and Human Services. The program’s current funding runs out at the end of 2017.
In Mokdad’s study, healthcare systems also had a significant effect on life expectancy. Not surprisingly, counties with a high percentage of uninsured residents have lower life expectancies.
Also not surprisingly, the quality of a county’s health care matters, “for example, how well your healthcare provider does in trying to control your high blood pressure,” says Dr. Mokdad. Counties with lower quality-of-care scores had lower life expectancies.
All that works in Fort Bend’s favor, and works against Polk. In 2014, 20 percent of Fort Bend residents were uninsured; that number is 29 percent in Polk. Fortunately, Texas has seen a significant decrease in the uninsured rate since the ACA was enacted in 2010. And if Texas were one of the states that accepted the Medicaid expansion under the ACA, the effect on the uninsured rates would have been even greater.
Fort Bend also has more doctors, dentists and mental health workers per resident than Polk.
There are significantly more challenges to stay healthy in places that are rural or poor.
As a general rule, Mokdad’s analysis shows, the higher a county’s unemployment, the lower its life expectancy is likely to be. In Fort Bend, in 2014, unemployment was 6.1 percent, a little below Texas’ average. In Polk County, it was more than 8 percent.
Fort Bend also has one of the highest median household incomes in Texas: $89,000. In Polk County, it’s $39,000.
And that’s connected to education. Fort Bend has one of Texas’ highest percentages of college graduates: 44 percent. Polk County: 12 percent.
SO WHERE do we go from here? How do we improve health in the state’s rural counties — the very places with deeply conservative values that dislike government interference? What else can we do?
We can encourage the formation of partnerships to promote public education, awareness, and access to healthier behaviors. Smoking cessation programs through the state of Texas are available. And towns like Livingston can get support through the CDC through its Partnerships to Improve Community Health program, which is a 3-year initiative that provides funding and other resources to help reduce chronic diseases like diabetes or heart disease. Texas is yet to have a city enrolled in this program.
But even if state and federal support is not given to these counties, local leaders have many options. Education and public awareness are one of them. Though most people know generally that healthy eating and physical activity is good for them, showing them specific and practical information will be far more effective. For example, most adults should get at least 150 minutes of moderate aerobic exercise (like a brisk walk) and strive for 2 or more days of strength training each week.
And the more you do, the better. Other research shows that if you increase those brisk walks to 200 minutes to 400 minutes per week, you will significantly reduce your risk of colon cancer and breast cancer.
Community interventions like these work. Though the U.S. has a growing life expectancy inequality, many of the solutions to this disparity can be simple. Still, healthy living isn’t a panacea, and the contrast between Polk and Fort Bend is clear: Counties where residents can be brought out of poverty and given access to meaningful and decent-paying jobs, higher education and quality health care are some of the healthiest places to live.
But we need to start somewhere, and giving these counties the tools to promote healthier living should make a significant impact to improve the quality of life — and life expectancy — of their residents.
I previously published this story in the Houston Chronicle.