Rural Somerset County is full of folks like Joe Reading, who used to dip his bare hands in DDT, still uses other chemicals on his farm and bathes his dinner greens in bacon grease. And Lewis W. Jones, a medical clinic director who smoked two packs of cigarettes a day until recently. And Weltonia Engram, who avoided getting Pap smears because she was afraid she might learn she had cancer.
Smoking, diets loaded with fat and salt, exposure to cancer-causing chemicals and poor access to health care may be clues to why one in 321 Somerset residents dies of cancer every year. Cancer statistics developed for The Sun show that the Eastern Shore's Somerset County has the second-highest cancer death rate among Maryland's 24 jurisdictions.
This year Maryland moved into first place with the highest cancer death rate of any state in the United States, and projections from the National Cancer Institute in Bethesda show that Maryland will retain first place next year.
Urban areas have long been known to be unhealthy, presumably because city dwellers are exposed to more industrial pollution. But the cancer risks to rural residents like those of Somerset only become clear when death rates for counties are compiled and examined.
To find out more about the types of cancers affecting Marylanders,The Sun asked the National Cancer Institute to rank states for different types of cancer and total cancer deaths for the last five years that data are available, 1983-1987. Then the state health department was asked to compute cancer deaths for the same five years for Baltimore and the state's 23 counties.
This picture emerged:
* Maryland's No. 1 ranking is propelled not only by high rates in Baltimore but also in the poor rural counties of the Eastern Shore, the midsize bedroom communities of Anne Arundel and Charles counties, and Western Maryland.
* Maryland ranks among the top six states for deaths from all the major cancers -- lung, colon, breast and prostate -- and is in the top four for esophagus; pharynx, the canal between the base of the skull and the esophagus; larynx, the voice box; liver; bladder; and multiple myeloma, cancer of blood plasma cells in bone marrow.
* The highest death rates for cervical cancer occurred in the poorest sections of Maryland -- the Lower Eastern Shore, Western Maryland, Baltimore and Southern Maryland -- a probable alarm that health education and access to care are deficient. Altogether, 406 Maryland women died of a cancer that health officials say need kill virtually no woman, because a Pap smear can detect cervical cancer while it is curable.
And the death rate for non-whites was three times that of whites.
* The highest cancer death rates for whites are in Baltimore and in Anne Arundel County.
* The racial differences in the rates for some cancers are so vast that state authorities should dig deeper for answers, said the National Cancer Institute official who directs the national system of collecting and reporting cancer incidence and deaths.
For example, the high lung cancer death rates for non-whites in Somerset County -- twice the rate for whites and nearly twice the state average for non-whites -- should be investigated, said Ben Hankey, director of the institutes's Surveillance, Epidemiology and End Results program.
A Somerset profile
Somerset is poised at the intersection of several risk factors.
In Somerset County, the southern tip of the Lower Eastern Shore, the seasonal landscape of fields chnages from cornstalks to soybean plants to golden fields of barley, wheat and rye. Roadside stands display the summer and fall harvest from truck crops.
But while Somerset produces a bounty from the land, it is the second-poorest county in Maryland.
Poverty and lack of education usually go together, said Dr. Ignatius L. DiNardo, medical director of the Somerset Medical and Dental Center in Princess Anne. "With an uneducated population, the corollary to that is a population that doesn't understand basic health care. Many of these people probably don't even know that smoking is bad for them."
Among Maryland's 24 subdivisions, Somerset has the worst death rates for lung, bladder and cervical cancers.
Smoking is the major cause of lung cancer and is blamed in about 40 percent of male bladder cancers and some cervical cancers. The state health department ranks Somerset second only to Baltimore in prevalence of smoking, and it is second to Baltimore in cancer deaths overall.
Seeing people smoking in public places is common in Somerset, even among some who know better.
Mr. Jones, 39, the medical clinic's executive director, took a last drag on his cigarette outdoors before stepping into his office to talk about cancer.
"I'm quitting," he promised. "As of today, it's a smoke-free zone" inside the clinic. The smoking ban went into effect after Dr. DiNardo gave a short lecture to employees about lung cancer, and everyone agreed that it looked bad for patients, who were being told by doctors not to smoke, to see staff members smoking in the clinic.
There are hazards beyond smoking. Although no major industry is located in Somerset County, people are coming into contact with cancer-causing chemicals in other ways. Somerset borders the polluted bay, farmers work with toxic chemicals, and 18 tons a year of one probable human carcinogen, tetrachlorethylene, has been released into the air by Carvel Hall Inc., a cutlery plant in Crisfield. The company plans to eliminate that pollution next year.
Added to that, many of Somerset's 19,400 residents are accustomed to high-fat, salty diets: homemade sausage, bacon and eggs, pork fat in the greens, pork cracklings in the corn bread, fried chicken, fried potatoes. Health professionals warn that a diet high in total calories, fat and salt, and low in fresh fruits and vegetables may be responsible for about one-third of all cancers.
But Eastern Shoremen don't like to be told how to stay healthy. "Watermen and farmers are the most independent people in the world," said Edward "Bunky" Price, auditor in the Somerset County commissioners' office. "We don't like dietitians telling us what we like to eat."
"People don't think what they eat is going to give them cancer," explained Joe Reading, 73, a hefty, outspoken farmer who cooks his greens "with plenty of bacon grease in it so when you put it in your mouth, it will slide right down your throat."
And there is a fatalism here at the Washington Hotel coffee shop in Princess Anne where about 20 farmers, watermen and other residents begin gathering at 6 a.m. daily over coffee and cigarettes. "You're going to die when your time comes," said Richard "Dicky Dumptruck" Reynolds, who runs a gravel pit and offers philosophy matter-of-factly between puffs on a cigar.
Thirty-one-year-old student Weltonia Engram says that in Somerset County, fear of cancer and lack of access to state-of-the-art care are also reasons for high cancer death rates. And health experts agree that that is the case in poor, outlying areas of the state. The economically depressed Western Maryland counties of Allegany and Washington, and Somerset and Worcester on the Eastern Shore, have cancer death rates for non-whites well above the state average.
Some residents raise questions about whether the Chesapeake Bay's world-renowned oysters and clams could be contaminated by a combination of toxic chemicals, including pesticide runoff.
Scientists have not done studies to determine whether there could be any link between contaminated shellfish and cancer. But "everybody's talked about it," said Larry Fykes, district manager of the Soil Conservation Service in Somerset County. "It's not proven, but you have to wonder. With the very intensive poultry-growing, manure's going back on all that land, heavy farming. Everything [runoff] goes into the tributary, which goes into the bay. . . . A lot of thought has been put into whether there is residual pesticide in [seafood]."
Shellfish are water-filtering organisms and known harborers of various pollutants. Dr. Clement L. Counts III, an expert on mollusks at the University of Maryland Eastern Shore, points out that the blue mussel is commonly used to monitor levels of pesticides and heavy metals in waters around the world.
Less is known about the ability of new pesticides to lodge in shellfish because little testing has been done. "These pesticides have hardly been looked at at all," said Dr. Dave Wright, a toxicologist at University of Maryland Chesapeake Biological Laboratory. "The toxics issue is a far stickier one politically [than other forms of pollution]."
This winter the Maryland Water Management Administration wants to begin testing several of the newer herbicides in streams near fields where they are used, said Deirdre Murphy, head of the water quality toxics section. But no money has been committed to the project yet.
Northeast coastal states have long been leaders in cancer death rates, and while cancer epidemiologists could not explain why, some said one reason may be a mysterious "urban factor," which generally includes exposures to cancer-causing chemicals. But researchers who have mapped cancer death rates for whites over the last three decades say that regional differences in cancer death rates are smaller.
Therefore, Maryland should be merging statistically with the rest of the nation, said Dr. Genevieve Matanoski, a Johns Hopkins epidemiologist who has spent decades investigating causes of cancer.
But while cancer death rates in other East Coast states have been dropping, Maryland's rates have moved into the lead, because so many areas of the state have big cancer problems, she said.
Populous Montgomery and Baltimore counties combined had more cancer deaths, but a lower death rate, than Baltimore, Dr. Matanoski pointed out.
"The lower rates [of Montgomery and Baltimore counties] . . . should bring [the state's rate] way down, and they don't," Dr. Matanoski said. The high rates in the Eastern Shore, Western Maryland and Anne Arundel, Charles and St. Mary's counties drive up the statewide rates, she said.
To put Maryland's experience in perspective, the state with the lowest cancer death rate is Utah, with 122 deaths per 100,000 population. Scientists believe that the strict Mormon lifestyle, avoiding smoking and drinking, is related to those low rates. Maryland has 194 deaths, and Delaware follows with 190.
Although it is not ranked as a state, the District of Columbia reports the country's highest rate, with 222 deaths, and some of its highest rates are found in cancers of the mouth, esophagus and larynx. In the district, where lung cancer rates are not high, the high rates of oral and neck cancers are thought to be linked to heavy alcohol use, according to Linda Pickle, a Georgetown University researcher.
Alcohol may be a contributor to Maryland's cancer problems, too. A 1987 telephone survey by the Centers for Disease Control in Atlanta found that Maryland had the highest rate in the nation of women who were chronic drinkers and was higher than the average nationally in the succeeding two years.
Just what role pollution plays in driving up Maryland's cancer rates is not clear, but under a recent federal law, there are some clues in reports now filed annually with the state Department of the Environment.
Industry discharges about 3 million pounds annually of cancer-causing chemicals into Maryland's air, ground and water.
Such discharges in Baltimore included the known human carcinogens benzene, which causes leukemia; chromium, which causes lung cancer; and nickel, which causes cancer of the lung and sinuses. Other counties where established human carcinogens were emitted included Anne Arundel, Baltimore, Caroline, Cecil, Dorchester, Howard, Kent, Montgomery, Prince George's, Somerset, Washington and Wicomico.
More specific information on industrial toxic releases may be obtained from the Toxics Registries and Analysis Division of the Environment Department. Its phone number is (301) 631-3800.
There is also heavy farm use of weed-killing chemicals and pesticides in Maryland. Last month, National Cancer Institute scientists said that one of the newer herbicides, 2,4-D, commonly used on Eastern Shore farms, should be declared a carcinogen.
"We think it's quite convincing that 2,4-D is probably causing non-Hodgkin's lymphoma," said Dr. Aaron Blair, NCI's chief of occupational studies, referring to two large studies that found farmers who used the weedkiller 20 or more times a year sharply increased their risk of the lymph system cancer.
"Overall the reports of these [cancer death] rates obligate us to try to find causes," said Ellen K. Silbergeld, professor of toxicology at the University of Maryland School of Medicine. "It demands that we start conducting some serious research."
The Delmarva Peninsula should be targeted for a major epidemiological study to determine causes of its high cancer rates, said Dr. Pickle, who has compiled U.S. maps showing the distribution of cancer cases.
Health officials in Maryland are finding it hard to get a clear understanding of the state's cancer problems because, even though statistics on cancer deaths are compiled, they do not yet have access to data on the number of new cases of cancer occurring each year.
Maryland began developing a statewide cancer registry eight years ago, but it still is incomplete, hampered by lack of a law requiring hospitals and laboratories to report all cancer cases.
A registry is a computerized record of cancer cases that is "the first step" in understanding who gets cancer and determining patterns of poor access to health care, bad diet, lack of education and other factors, said Dr. John N. Lewis, who heads preventive medicine for the Baltimore Health Department.
The state may seek a mandatory reporting law in the 1991 legislative session, said Dr. Boon P. Lim, the Department of the Environment official responsible for the cancer registry. Dr. Lim said he hopes to finish the job of entering information into the University of Maryland medical school computer next year, then update it annually.
Although Maryland faces obstacles to determining the causes of its high cancer death rates, state officials formed the Maryland Cancer Consortium this year to begin programs dedicated to preventing and stopping tobacco use and and detecting breast and cervical cancers early. The statewide plan is funded under a seven-year National Cancer Institute grant of $120,000 annually that began last year.
"What we have decided to do is concentrate on the cancers we can do something about," said Dr. John W. Southard, an administrator in the state health department.
In Baltimore, the Health Department has applied to the National Cancer Institute for a grant to find out if community education programs and improved early diagnostic services in a predominantly black area of Northwest Baltimore will make an impact on its above-average cancer death rates.
"The concept of early intervention is strange," said Bernellyn Carey, the city official in charge of health education. She finds that typically people "are crisis-oriented" and "react to signs -- pain or bleeding."
The city needs to do more than just educate citizens about early detection of cervical and breast cancer, she said. "It's not fair to the public to educate them and then not have follow-through" care that is available and affordable. That is a problem in the city, she said.
And across the Bay Bridge, help cannot arrive too soon.
The two obstetrician-gynecologists who performed Pap smears at Somerset's only federally funded clinic left in July, and it is hard for the clinic to find replacements. Consequently, cases of cervical cancer will likely increase, predicted Dr. DiNardo, the clinic's medical director.
At Washington High School in Princess Anne, students interviewed said smoking is increasing and estimated that from one-third to more than half of the students smoke.
"The diets out here are unbelievably fattening," laments unusually diet-conscious Robert S. Fitzgerald, director of business for the Somerset County Board of Education. "Chicken and dumplings, fried foods, scrapple smothered in molasses."
"The 'me' generation hasn't really hit Somerset County," said Dr. DiNardo. "People here don't jog. They don't watch what they eat. They're not really health-conscious here. We haven't hit that yet, and we may never hit that."
Top 25 states
1983-87 cancer deaths per 100,000 people:
*1. MARYLAND 194.1
2. Delaware 189.9
3. Alaska 189.4
4. Louisiana 186.5
5. New Jersey 185.4
6. Nevada 185.0
7. Ohio 182.3
8. Virginia 181.7
9. Rhode Island 180.6
10. Kentucky 180.5
11. Maine 180.3
12. Massachusetts 179.4
13. Pennsylvania 178.6
14. New Hampshire 178.5
15. Indiana 177.1
16. New York 177.0
17. Vermont 177.0
18. Alabama 176.4
19. Michigan 176.3
20. Illinois 176.0
21. West Virginia 175.5
22. Georgia 173.6
23. Connecticut 173.2
24. Tennessee 172.6
25. Missouri 170.6
* The District of Columbia has the highest rate, 221.8, but is not a state. Rates are age-adjusted, since some states have larger populations of elderly people.
Source: National Cancer Institute