Georgia has a cancer problem. All parts of the country do, of course, but Georgia's is one of the more discouraging ones. The overall state death rate among men from lung and prostate malignancies is 20 percent higher than the national average. More than one in three Georgia residents can expect to contract some form of the disease over the course of their lifetimes. And treatment is uneven, with blacks 27 percent more likely than whites to die of cancer, and rural residents suffering mortality rates significantly higher than in the cities and suburbs.
Over the years, Georgia's elected leaders have dealt with this situation pretty much the same way other states have dealt with it. That is, they have accepted fate and taken whatever money the federal government was willing to provide. And yet the state--the nation's ninth largest in population--ranks just 27th in the country in receipt of federal cancer research dollars.
Under its current governor, Roy Barnes, Georgia is trying something very different. Barnes has decided that the state needs an ambitious cancer program of its own. He is committing big money to it: $400 million in state funds over 10 years, an amount that includes a good chunk of the money available to the state from the legal settlement with tobacco companies.
It's not just the money that represents a breakthrough in health policy. It's the philosophy behind it. States, although they regulate health care institutions and devote large sums to cancer treatment through Medicaid, have historically done little to combat cancer as a whole. They have had to be prodded even to maintain registries of cancer and tumor cases within their borders. Research funding has, for the most part, been viewed by states as a responsibility of the federal government.
One of the central aims of Georgia's project is to change those attitudes. "Part of the problem of controlling cancer has been this major disconnection between what we know we can do already in America to save lives and what we're actually doing about it," says Jonathan W. Simons, director of Emory University's Winship Cancer Center, who was personally recruited by Barnes to spread the gospel of prevention and to oversee the $100 million research facility currently being built on the Emory campus.
Despite the heavy commitment in state funds--the legislature appropriated $60 million this year alone--Georgia's cancer project is a public-private partnership. In addition to the state's eventual $400 million, the plan is for some $600 million to be raised from federal, philanthropic and various private sources. The state is hoping to set up a large matching-grant pool, in which tobacco-settlement dollars are used to leverage and attract other money. The scheme has enjoyed some notable success already. The Avon Products Foundation alone has given $7.5 million, its donation tied to the legislature's appropriating funds for a new cancer clinic at Atlanta's public Grady Memorial Hospital.
The enabling legislation in Georgia was written in such a way as to avoid setting up big and costly new divisions within the state health department. A smaller coordinating board has been charged with dispensing grants, promoting cancer education and looking at the big picture on research and equal access to treatment.
No other state has enacted anything as dramatic as Georgia did this year, but states across the country are beginning to get the idea that there are better things for them to do in the cancer war than simply wait for federal money to come in.
In the past two years, for example, 19 states have asked for and been given waivers of federal law so that they can use Medicaid dollars not only to screen low-income women for breast cancer but to actually treat the sick women they diagnose. Another 27 states have started the waiver process. Other small but concrete steps are being taken in a variety of places. North Carolina, for instance, has approved new funding for colorectal screenings and has improved the test used by the state's doctors for cervical cancer. This year, 14 states passed laws requiring insurers to pay for routine costs of care, such as blood work, that result when patients participate in clinical cancer trials. Before taking up his job in October as federal head of Homeland Security, Pennsylvania Governor Tom Ridge played a leading role in the National Dialogue on Cancer, calling on each state to have a comprehensive plan on its books by 2005 and a statewide cancer registry by 2003.
Pennsylvania has one of the more active and ambitious cancer programs outside Georgia. The state's efforts began as far back as 1980 but have stepped up since the 1998 tobacco settlement. Pennsylvania is now devoting $65 million in tobacco money specifically to cancer research and is raising additional capital with a voluntary income tax checkoff. The state funds research and runs targeted media campaigns aimed at citizens thought to be at greatest risk.
The federal Centers for Disease Control and Prevention has begun encouraging states to address the problem of cancer generally, to track related diseases and monitor whether resources are being devoted proportionately to different areas within state borders. The aim of such comprehensive planning is to increase the likelihood of capturing some of the risk factors that overlap many different cancers. States are responding to the challenge. Several have developed comprehensive monitoring plans, while others are scrambling to do so under deadlines imposed by legislatures or by executive order.
Texas has been in the cancer planning business since 1985, when it established a coordinating board to keep track of its programs. The Texas Cancer Coalition is a modest effort, currently funded at $4 million a year, but it does award grants to 27 different initiatives around the state, and works with the Texas Medical Association to provide oncology training to family practitioners, disseminating information through seminars, a volunteer speakers bureau and the Web. "If one is practicing in Houston, then a physician has lots of resources available to them," says Mickey L. Jacobs, executive director of the Texas coalition. "In contrast, a rural physician might not be as well prepared."
A focus of the Texas effort is early detection of colorectal cancer. Ninety percent of patients with the disease survive when it is detected prior to metastasis, but only about 8 percent survive if treatment doesn't begin before then. Harrison County in East Texas, noticing from its research that it has a higher rate of colorectal cancer than its neighbors, applied for a grant from the state coalition to encourage African-American males to get tested. Advertising in a minority newspaper and on gospel and oldies radio stations, and making in-person presentations to groups, the program in its first year offered counseling and other information services to 2,850 individuals, referring 115 of them to the county's two gastroenterologists for colonoscopies. "We are trying to reach a group who never thought of having colon screening," says Georgia Grant, the program director at the Longview Wellness Center. "For those who saw Katie Couric and still didn't get enough information, we're filling the gap."
In addition to recruiting more patients for treatment, states are placing new emphasis on getting long-term research done at home. Another important aspect of many state cancer efforts, after all, is the hope of reaping economic benefits. The conventional wisdom holds that biotechnology will be the nation's next great growth industry, and one incentive for investing substantial funds in the cancer war-- in addition to saving lives--is to be competitive in that field.
In Georgia, Governor Barnes has declared a goal of attracting 150 top cancer scientists to Georgia over the next six years. In September, he announced the hiring of specialists from many of the best-known research facilities in the country, including the National Cancer Institute, the Memorial Sloan-Kettering Cancer Center and Johns Hopkins, Stanford and Harvard universities. Meanwhile, Augusta, Savannah and other Georgia cities are already bidding to host the next cancer center that will get state funding.
"If you're attacking the cancer problem and growing the research communities," says Emory's Jonathan Simons, "it actually increases the intellectual capital. It is about improving the health of Georgians but just as much about growing economic health in Georgia."