By Charlotte Huff for KFF Health News.
Broadcast version by Freda Ross for Texas News Service reporting for the KFF Health News-Public News Service Collaboration

The night before her chemotherapy, Herlinda Sanchez sets out her clothes and checks that she has everything she needs: a blanket, medications, an iPad and chargers, a small Bible and rosary, fuzzy socks, and snacks for the road.

After the 36-year-old was diagnosed with stage 3 breast cancer in December, she learned that there weren't any cancer services in her community of Del Rio, a town of 35,000 near the Texas-Mexico border.

To get treatment, she and her husband, Manuel, must drive nearly three hours east to San Antonio. So they set an alarm for 4 a.m., which allows for just enough time to roll out of bed, brush their teeth, and begin the long drive navigating dark roads while watching for deer.

About an hour before they arrive at the cancer clinic, the couple pulls over to quickly eat fast food in the car. The break gives Herlinda time to apply ointment on the port where the needle for her chemotherapy will be inserted.

"It numbs the area, so when I get to the infusion room the needle won't hurt," she said.

For rural patients, getting cancer treatment close to home has always been difficult. But in recent years, chemotherapy deserts have expanded across the United States, with 382 rural hospitals halting services from 2014 to 2022, according to a report published this year by Chartis, a health analytics and consulting firm.

Texas led that list, with 57 rural hospitals - nearly half of those statewide that had offered chemotherapy - cutting the service by 2022, according to the analysis. Rural hospitals in states like Texas, which hasn't expanded Medicaid, have been more likely to close, according to data from the Cecil G. Sheps Center for Health Services Research.

To keep the doors open, financially strapped facilities in small communities nationwide continue to shed basic health care services, like obstetrics and chemotherapy, said Michael Topchik, executive director of the Chartis Center for Rural Health.

"The data are staggering," Topchik said. "Can you imagine feeling that sick, and having to drive an hour in each direction, or maybe more each direction, several times a week?"

Loss of chemotherapy services can signal other gaps in cancer care, such as a shortage of local specialty physicians and nurses, which is bad news for patients, said Marquita Lewis-Thames, an assistant professor at Northwestern University in Chicago whose research covers rural cancer care.

Rural patients are less likely to survive at least five years after a cancer diagnosis compared with their urban counterparts, concluded a study co-authored by Lewis-Thames and published in JAMA Network Open in 2022. While the rural-urban survival gap narrowed over the nearly 40 years researchers studied, the disparity persisted across most racial and ethnic groups, with only a few exceptions, she said.

Many cancer drugs are now given orally and can be taken at home, but some treatments for breast, colon, and other common cancers must still be administered intravenously inside a medical facility. Even distances of an hour or two each way can strain patients who already may be coping with nausea, diarrhea, and other side effects, physicians and patient advocates said.

"It's pretty uncomfortable for some of these patients who may have bone metastases or have significant muscular pain and have to sit in the car that long and hit road bumps," said Shivum Agarwal, a family physician who practices in rural communities an hour west of Fort Worth, Texas.

Plus, travel can cost much more than filling the gas tank.

"Usually it requires an able-bodied family member taking off a whole day or at least half a day from work," Agarwal said. "So, there's a big economic cost for the family."

In this sense, the Sanchez family is fortunate. Herlinda's mother drives four hours from Abilene to Del Rio to watch the couple's youngest children, their 2-year-old twins.

Cancer infusions can last as long as eight hours on top of the travel time, causing significant financial and logistical challenges, said Erin Ercoline, executive director of the San Antonio-based ThriveWell Cancer Foundation. The nonprofit provides adult patients with financial assistance, including for gaps in insurance and transportation-related costs. It has helped cover gasoline for Sanchez, who received her final round of chemotherapy in late June. The financial assistance will also pay for her hotel when she travels for breast surgery this month.

Not all rural hospitals are ending chemotherapy. Childress Regional Medical Center, a 39-bed hospital in West Texas, is constructing a 6,000-square-foot center for patients who need infusions for cancer and other diagnoses, including multiple sclerosis and rheumatology.

The infusion area, which started with two chairs in 2013 and now has four, will grow to 10 chairs and have more patient privacy when it opens next year. The next-nearest infusion center in this sprawling region is an hour or more away, which discourages some patients from seeking care, said Childress' CEO, Holly Holcomb.

"We've had a handful of patients say, 'If you can't do it here, I'm not doing it,'" Holcomb said. She credits the federal 340B drug discount program for enabling the remote hospital to provide infusion drugs.

Hospitals that qualify for 340B can buy outpatient drugs at steep discounts. The program provides "a huge kickstand for rural hospitals," said Topchik, of Chartis Center. Hospitals can use the savings to buoy or expand services provided to the community, he said.

But some patients are not daunted by long drives and travel costs.

"I'm from the country, so small is better - it's just more personable," said Dennis Woodward, 69, who lives in Woodson, Texas. He has a type of non-Hodgkin lymphoma and chooses to make a two-hour drive to Childress. He had first visited an oncology clinic in Abilene about an hour away. The clinicians were nice, but "I felt like a number," he said.

After his first appointment at Childress this year, his oncologist, Fred Hardwicke, walked him over to meet the nurses who would administer the medicine, Woodward recalled.

Most Fridays during Herlinda Sanchez's chemotherapy, Manuel would nap in the car. But during her final treatment in June, he stayed nearby, counting down the hours.

Several family members joined Herlinda when she rang the bell later that afternoon to signal the end of her treatment.

"I don't want to be in San Antonio no more," said Herlinda, a mother of four who does administrative work at Laughlin Air Force Base near Del Rio. "I'm looking forward to the break."


Charlotte Huff wrote this story for KFF Health News.

In this year's devastating hurricane season, Florida community health centers are proving indispensable in disaster response and recovery, providing far more than medical care.

The back-to-back blows of Hurricane Helene and Hurricane Milton left the region reeling, testing the resilience and adaptability of health care providers.

Kim Schuknecht, chief operating officer of Evara Health in Pinellas County, said they had plans to deploy mobile units to beach communities after Hurricane Helene but Milton's swift arrival and widespread flooding thwarted the efforts.

"By the time we were able to get that all worked out with the mayors of the different areas, here comes Milton," Schuknecht recounted. "We weren't even able after the first hurricane to get out there. That really was an inhibitor for us to be able to go out and do some mobile services because so many areas, we couldn't drive in them."

She pointed out they extended their operating hours to navigate those challenges. While providing services at emergency shelters, they discovered people were asking for help with needs beyond behavioral health and medical care. They ended up gathering supplies so evacuees could take showers in one of the mobile units.

Schuknecht noted one lesson learned is the demands were greater than anticipated, even beyond basic medical care.

"Baby wipes, things that we -- hadn't been through this type of situation before -- things that you just take for granted and don't really think about," Schuknecht explained. "We've learned to have more supplies on hand, different supplies than what we're used to."

As Florida looks ahead to the next hurricane season, Schuknecht noted her operation is refining its emergency preparedness strategies. Plans include more tabletop exercises and strengthening new collaborations, such as a partnership with the Red Cross, which she emphasized will be crucial for future responses.

Schuknecht added this season's experiences have shaped her company's approach to future planning, ensuring they remain a cornerstone of support in the face of Florida's unpredictable storms.

"I think we all learned a lot," Schuknecht acknowledged. "All of the agencies here in the county, including Evara Health, we were very fortunate to be able to have the resources to assist. And we're glad we were called upon to be able to provide the care that we did."


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Alabama faces a critical workforce gap, with only 38 available workers for every 100 open jobs, according to the U.S. Chamber of Commerce.

To address the issue, Black community colleges are stepping up as key players in preparing skilled workers for in-demand industries. The schools are coming together at the second annual EmpowerED Conference to explore ways to expand opportunities for students.

Chandra Scott, executive director of Alabama Possible, said the event will also include Historically Black Colleges and Universities and focus on creating seamless transitions from two-year community colleges to four-year universities.

"We want to make sure that there are streamlined pathways from the community college to an HBCU," Scott emphasized. "We don't want any credits lost. We don't want any time wasted and any money frayed away."

She explained they hope to achieve the goal by connecting educators, students and industry leaders to find solutions to Alabama's workforce challenges and elevate the work within the institutions. The two-day conference is Feb. 11-12 in Mobile.

Scott pointed out another key focus will be showcasing the contributions historical and predominantly Black community colleges make to the state's workforce. With Alabama's economy depending on industries like aerospace, manufacturing and shipbuilding, she noted the schools play a critical role in training diverse, skilled workers who are ready to fill gaps.

"Most of the students who come through these institution doors are first-generation, from under-resourced families and they are from families of color," Scott outlined. "Now, you're able to diversify what your workforce looks like and you're pulling on excellence because they are getting trained and credentialed in specific pathways."

In a state where the labor participation rate is below the national average, Scott added the EmpowerED Conference discussions could play a significant role in shaping Alabama's economic future.

Winter conditions across Michigan are fickle and The Michigan Department of Natural Resources is urging everyone to prioritize safety while enjoying the season's cold-weather adventures.

The DNR advised outdoor enthusiasts to prepare by dressing in layers, checking weather and road conditions, and carrying essential safety gear such as flashlights and ice picks.

Sgt. Jason Becker from the Law Enforcement Division of the DNR said it is also important to stay hydrated and not go out alone if possible. He offered a potentially life-saving tip:

"Let someone know where you're gonna be and approximately what time you're going to return," Becker recommended. "If something does happen, we know where to start looking or we even know that you are missing. We always tell people, 'Go with a buddy,' especially when it comes to snowmobiling because it tends to be far away from civilization."

Becker also stressed carrying a two-way communication device capable of working in remote areas and taking an honest assessment of your health. If you are not feeling well, stay home.

In Michigan, statistics show snowmobiling and hypothermia are leading causes of injury or death in winter recreational accidents. However, falling through ice, especially during ice fishing, remains a serious risk. In 2019, there were 65 fatalities from 54 ice-related accidents.

Becker emphasized a critical saying from the DNR: No ice is safe ice.

"Carry an ice pick so that if you do fall through, they're a way to get some traction in the ice to pull yourself back out of the water," Becker urged. "Have something to make a hole in the ice, to check the thickness and keep checking it periodically."

He added alcohol consumption is a big factor in many accidents during recreational activities.


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