EDITOR’S NOTE: This story was reported in collaboration with the Global Health Reporting Center with support from the Pulitzer Center.
Andy Henard is used to doing things for himself. That’s the way to run a successful ranch and farming operation in North Texas. “I’ve always been a big strong guy. If I need to load 50 sacks of wheat seed weighing 100 pounds, I just do it,” says Henard, 76, a former Texas A&M defensive end.
But for the better part of a year, it was all he could do to drag himself from the couch to his bedroom. In late 2023, the week before Christmas, Henard was diagnosed with stage IV bladder cancer. Less than two years earlier, he’d undergone surgery for prostate cancer, the same disease that killed his brother. This was worse.
Treating early-stage prostate cancer was one thing, but Henard’s doctor at the small rural hospital nearby told him the new diagnosis called for a meticulous, highly sophisticated form of treatment. Henard booked an appointment at MD Anderson Medical Center in Houston, eight hours and 500 miles away.
Long drives are a big part of life in rural America, but transportation is uniquely challenging for people who are ill, elderly or both. Rural cancer patients tend to be diagnosed later and have worse outcomes. Although cancer is no more common in rural places than in cities or suburbs, rural patients are about 9% more likely to die of it.
According to a study published in September by the American Cancer Society, rural patients are also less likely to receive treatment that meets the standard of care. “We see a lot of delayed treatment, because people don’t get diagnosed early enough, because they’re not seeing doctors,” says Brock Slabach, chief operations officer of the National Rural Health Association.
Henard and his family grow wheat, cotton and peanuts, and raise about 500 head of cattle on a piece of land that’s been in the family for more than a century. There’s no big city nearby. It’s 180 miles to Lubbock, 240 to Oklahoma City, 280 to Dallas. To get the cutting-edge treatment that seemed like his only hope, Henard assumed he would have to move to Houston for a year, maybe more. It would mean finding a way to leave the ranch in someone else’s hands.
But after two days of meetings at MD Anderson and a flurry of calls with his hometown doctor, Henard was stunned to learn that he wouldn’t have to uproot his family at all. The doctors worked out a way to deliver Henard’s chemotherapy at Childress Regional Medical Center, just 30 minutes down Highway 83 from the ranch in Wellington.
At a time when smaller hospitals and clinics across the country are closing or reducing services, Childress did the opposite: opening a small infusion center in 2013 and steadily expanding its capabilities in order to serve patients like Henard.
It was a risky bet, but Holly Holcomb, Childress’ CEO, says the move was sparked by a loss that shook the whole community. That was Terry Olay, the outpatient services coordinator at Childress, who died of cancer herself in 2009.
“When she was sick, she was driving to Amarillo, which is 100 miles away,” Holcomb said. “And she said, ‘There’s no reason Childress can’t do this.’ ”
Other local cancer patients were spending even more time on the road. “We had people getting chemo three times a week. It was the equivalent of driving to San Francisco and back, every week.”
The infusion center started with two chairs but has since grown to encompass 10 spots for patients, three full-time pharmacists and three full-time oncology nurses.
Dr. Fred Hardwicke is a big part of Childress’ ability to buck the larger trend. Hardwicke was head of the oncology-hematology fellowship program at Texas Tech when, shortly before Thanksgiving in 2014, his boss asked him to see a few patients in Childress, more than two hours away. At first, it was one visit a month, but he quickly recognized an unmet need.
Hardwicke, who loves numbers to the point where he wrote and self-published a mathematics textbook, did the math around his new gig. “I figured, it’s one drive for me, versus 20 drives for them. That’s a lot of gas.”
More than that, he found the work invigorating. “When I got to actually see the patients there, they were so appreciative. It just pumps you up and makes you want to do it.”
At first, he increased the number of visits to Childress. In 2021, his boss cleared him to move there and set up a full-time oncology clinic.
For Hardwicke, it’s a perfect match. Even though he’s now 65, he has no immediate plans to retire. But the longer-term future for Childress is challenging. Early-career oncologists are only half as likely as late-career peers to practice in rural areas, according to a recent analysis by the American Society of Clinical Oncology. The report predicts that by 2037, non-urban areas will have only 29% of the specialists needed to meet demand.
“The problem boils down to a lack of qualified providers willing to serve in underserved areas,” says Dr. Mohamad Al-Rahawan, a pediatric hematologist/oncologist at Texas Tech University Health Sciences Center and executive director of the Rural Cancer Collaborative.
Al-Rahawan emphasizes that the challenge isn’t unique to cancer or even health care. Instead, he says, it’s a real-life version of the Disney film “Cars,” a movie he’s seen countless times in the pediatric cancer ward. In that animated film, the town of Radiator Springs is slowly dying after a new interstate takes all the traffic. As Al-Rahawan sees it, “If a town can’t support a grocery store any more, how can it support a hospital? Or an infusion center?”
For the first seven months of 2024, Henard received infusions of Pavced, a targeted form of immunotherapy that has driven up survival rates from bladder cancer. In addition, for almost two years, his wife, Deltah, drove Henard to Childress every Tuesday for infusions of Keytruda, an immune checkpoint inhibitor used to prevent recurrence of disease by attacking stray cancer cells that may still be circulating in the body.
The regimen wasn’t easy. “Chemo’s very hard on you,” says Henard. Food tasted like cardboard, and he went from 235 pounds all the way down to 180. But by this past fall, he was cancer-free. “I haven’t gotten all my strength back, but I’ve got a son here working with me, and I’m working again. I’ve been blessed with everything,” he says.
Many rural patients aren’t so lucky. A recent report from medical consulting group Chartis found that 448 rural hospitals – nearly a quarter of the nation’s total – stopped offering chemotherapy services between 2014 and 2024. Texas lost more centers than any other state, making Texas Tech and Childress Medical Center oases in a spreading health care desert.
“The problem is distance,” says Al-Rahawan. “With some diagnoses, you’re told you have six months to live. In that situation, you don’t want to spend six months on the road.”
Even when patients have transportation and resources, many are forced into tough decisions. Proton beam therapy is a form of radiation treatment that delivers a highly precise dose to the tumor, sparing the surrounding tissue and thus reducing side effects. It’s used to treat many forms of cancer and is commonly used in pediatric cases. But there are fewer than 50 proton therapy centers in the United States.
Al-Rahawan recently treated an 8-year-old with a tumor on his spine. The family has two younger children in school and no nearby relatives, so after their eldest child finished chemotherapy, they opted for traditional radiation treatment at Texas Tech instead of moving the whole family to Dallas or Oklahoma City. “If [patients] need proton beam radiation, they’ll have to drive five to 10 hours,” says Al-Rahawan. The older form of treatment has more side effects, “but for some people, that’s the best alternative.”
Geography is just one hurdle. As cancer care becomes both more advanced and more specialized, options in rural areas have shrunk. Nationwide, there are 6.6 oncologists for every 100,000 people in urban areas. In rural areas, there are just 2.2 per 100,000. Most rural counties have no oncologists at all.
“Twenty-five years ago, there were a lot more small private practice oncology groups, especially in rural areas. It would be even single doctors, with a nurse,” says Dr. Neil Hayes, chief of oncology at the University of Tennessee Health Science Center. But rising costs essentially forced these small practitioners to flee to the safety of larger hospital systems, according to Hayes. That’s because if a patient can’t pay or an insurer kicks back a claim, a small practice in a rural area can be on the hook for tens or even hundreds of thousands of dollars.
Many new medications are far more expensive than the standard chemotherapy of the 1990s and early 2000s. “You’ve got drugs that cost $300,000 a treatment. Back then, it might have been $300,” says Al-Rahawan.
Increasing complexity of care is also a big factor. “Twenty-five years ago, a nurse grabbed a vial [of chemotherapy medication] and just gave it by the bedside,” says Al-Rahawan. “Things were simpler. Not safer or better, but simpler.” These days, he explains, a pharmacist, a specialty nurse and oncologist will carefully weigh the pros and cons of various protocols. Their professionalism has raised the overall level of care, in his view. “All this complexity basically helped increase survival and success rates,” he says. “But those tools are making it harder for rural hospitals to provide all those pieces.”
Texas has taken steps this year to try to address a perceived shortage of physicians overall, joining at least 17 other states in making it easier for foreign medical graduates to practice in the United States. But it’s unclear what impact that will have, and rural areas in other states face similar obstacles to filling critical roles.
In Washington state, the Confluence Health hospital system launched an ambitious effort to build a $14 million state-of-the art radiation therapy site at its campus in Moses Lake, about midway between Seattle and Spokane. The site opened in 2023, but for more than three years, Confluence was unable to find a radiation oncologist to oversee the program, relying instead on a mix of temporary hires.
“To live in a remote kind of place where things move at a slower pace takes the right kind of person,” says Spencer Green, the oncology service line director for Confluence, who originally hails from the small town of Sterling, Colorado. One full-time radiation oncologist came but left soon after. Then, says Green, “We passed on a couple of people who might have taken the job because we thought, ‘I don’t think this person’s going to stay. Eight months later, they’re going to go, “I can’t do this.” ’ ”
Finding an oncologist wasn’t the only problem. In the past three years, Green was able to find only one of the three full-time radiation therapists he was hoping to hire. “I think this is going to be a trend for a lot of places like us,” he says. “We keep getting more and more patients to take care of, but we’ve been putting out the same amount of doctors and therapists and everything else for a hundred years. Sooner or later, there’s just not enough providers to take care of that amount of patients.”
Ultimately, Green had to look beyond traditional job postings. The second full-time radiation therapist at Moses Lake will be a woman who started as a receptionist and spent the past two years taking coursework and going through on-site training to prepare for the new role. Says Green, “In some cases, it’s ‘grow your own.’”
What’s more, just last month, Green says, he finally landed his new oncologist. “We have a new one coming here in May, which is fantastic,” he says. “I think they’re going to be a good fit because they came from a kind of smaller area too and they have a connection to the Pacific Northwest.”
But oncologists and hospital administrators say pressures are likely to worsen over the next few years as provisions of the “Big Beautiful Bill” kick in that are projected to leave about 10 million more Americans without insurance over the next decade, mostly through cutbacks to Medicaid.
According to Chartis, 40% of rural hospitals already operate at a loss, and many hospital administrators say they could be forced to reduce services, or worse, if fewer patients have insurance to pay for their care. To some extent, this has already happened: Six of the seven states that saw the highest proportion of chemotherapy services cut are states that declined to expand Medicaid under the Affordable Care Act and so have higher rates of uninsured.
In recognition of these financial pressures, Congress last year authorized $50 billion in “rural health transformation grants,” to be spent over five years, to promote innovations that might benefit rural patients – for example, expanded telehealth options. But that number is well short of the $140 billion that rural hospitals are expected to lose due to Medicaid changes. What’s more, the money isn’t supposed to be used to subsidize basic care, like Childress’ infusion service.
In two years of Tuesday visits, Henard saw a lot of familiar faces at the infusion center. He got to know his fellow patients. He noticed when someone wasn’t there for a while. That could be good news or bad. He grew close to the receptionists, the techs and oncology nurse Kathy Ivy, a neighbor of his from Wellington who’s been at Childress since the infusion center opened.
On his last day, Henard recalls, “They said they’re gonna walk me out. I laughed and said, ‘I know the way to the front door.’ But she said, ‘hush, I’m gonna walk you out.’” When he followed Ivy around the corner to a long hallway, the sight and sound took his breath away.
“We turn the corner, and it’s lined up with people ringing bells. People I’ve known all my life. Doctors, friends – it’s a small community.”
Henard walked down the corridor, bells ringing all around him, to the double doors heading out, where Ivy gave him his own bell to ring, right there.
“Not everyone gets to ring that bell,” he says. “It was a very, very humbling experience to feel all the love that was shown.”