The Upland South

A fifth-generation farmer stands on land his family has worked since the 1840s. His grandfather built the tobacco curing barn still standing at the field’s edge. His father expanded the tobacco allotment that paid for his education. The allotment was the family’s most valuable asset, passed down like land itself.

Now he has diabetes, no health insurance, and deep suspicion of government programs that he associates with the decline of everything his family built.

The 2004 tobacco buyout ended the quota system sustaining small tobacco farms for seven decades. His buyout payment of $12,000 annually for ten years ended in 2014. He diversified into hay and cattle, but neither pays like tobacco did. The curing barn sits empty. He did not sign up for Medicaid expansion because his state did not expand, and even if it had, he would view accepting government healthcare as admitting defeat.

How does transformation reach him?

This is the central question for the Upland South, the Piedmont and hill country stretching from Virginia through the Carolinas, Tennessee, and Kentucky. Tobacco country. Small-farm country. Evangelical country. A region where strong community bonds coexist with deep distrust of outside intervention, where health outcomes are poor but communities resist being characterized as problems to be solved.

The Upland South is not the Delta or Appalachia. It lacks their extreme poverty and isolation. But it faces its own transformation challenge: engaging communities whose cultural identity includes resistance to the very programs that might improve their health. Economic transition from tobacco has left communities searching for identity and income while healthcare needs grow.

Regional Definition

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The Upland South encompasses Piedmont plateau and foothill terrain between the Appalachian Mountains and the Coastal Plain. Unlike the flat Delta or rugged Appalachia, this is rolling country: hills but not mountains, farms but not plains. The terrain is gentle enough for agriculture but too hilly for plantation-scale operations.

Core territory includes:

Virginia Southside: Counties from the North Carolina border north to Lynchburg, historically centered on tobacco around Danville, South Boston, and Martinsville. The region’s textile and furniture manufacturing supplemented tobacco agriculture before both declined.

North Carolina Piedmont: Counties from the Virginia border through Burlington, Greensboro, and Winston-Salem, historically the heart of bright leaf tobacco production. The tobacco auction houses are closed, but their architecture remains.

South Carolina Upstate: Northern counties including Greenville and Spartanburg. This area has attracted manufacturing investment that other Upland South counties have not, creating economic variation within the region.

Tennessee Middle and East: Counties between Nashville and the mountains, including the Cumberland Plateau. Burley tobacco country with cultural patterns similar to Kentucky.

Kentucky Burley Belt: Central Kentucky counties around Lexington, historically growing burley tobacco distinct from the flue-cured varieties further south. The bluegrass region has diversified into horse farming and bourbon tourism; surrounding counties have struggled more.

Northern Georgia and Alabama: Piedmont counties transitioning to Appalachian foothills, sharing cultural patterns with the broader region.

The region contains approximately 8-10 million people. What unifies it is historical tobacco economy, Scots-Irish cultural heritage, evangelical Protestant tradition, and small-farm agricultural structure.

The Upland South is not Appalachia, though it borders Appalachian territory. Appalachia’s identity centers on mountains and coal; the Upland South’s identity centers on rolling hills and tobacco. Appalachia received decades of federal attention through the Appalachian Regional Commission established in 1965. The Upland South has no regional commission, no policy identity, no federal attention as a distinct region.

This intermediate position creates policy invisibility. The Upland South is neither poor enough to demand Delta-style crisis response nor geographically distinctive enough for Appalachian-style regional programming. It is ordinary rural America, which means it receives ordinary programming insufficient for its particular challenges.

Cultural Distinctiveness

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Upland South culture reflects Scots-Irish heritage from colonial settlement. Waves of migration from Ulster and the Scottish lowlands through the 18th century established cultural patterns that persist. Understanding this heritage is essential for effective transformation.

Evangelical Protestantism: Baptist and Methodist churches anchor community life in ways that secular institutions cannot replicate. Faith shapes worldview, social relationships, and attitudes toward government. The church provides social services, counseling, emergency assistance, and meaning. Church membership creates social networks that secular programs cannot access. Ministers and deacons are trusted; government officials are not.

Independence and Self-Reliance: Government assistance carries stigma that accumulates across generations. Accepting help signals failure to provide for oneself and one’s family. Neighbors help neighbors, kin help kin, but government help implies inability to manage one’s own affairs. This orientation affects healthcare utilization even when coverage is available.

Distrust of Outsiders: Communities experiencing decades of outside characterization as backward, poor, or in need of rescue develop protective suspicion. Academic researchers, government officials, and healthcare reformers arriving from distant cities represent outside judgment. Health interventions designed in Washington or state capitals are presumptively suspect until proven otherwise.

Strong Family and Community Bonds: Despite resistance to formal programs, communities exhibit remarkable mutual support through churches and extended family. Families care for elderly members at home. Neighbors organize meal deliveries for the sick. Churches collect offerings for families facing medical emergencies. These bonds are genuine health assets that transformation should engage rather than replace.

Honor and Reputation: Social standing matters intensely. Being seen as needing help damages reputation. Pride prevents seeking assistance even when assistance would help. This cultural logic affects healthcare seeking behavior in ways that utilization statistics cannot capture.

Historical Context

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The Tobacco Economy

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Tobacco shaped the Upland South for four centuries. Unlike large-scale plantation agriculture of coastal regions, Upland South tobacco was small-farm agriculture. The crop’s labor intensity made it unsuitable for large-scale mechanized production. Families grew tobacco on 5-50 acre allotments, with labor provided by family members and neighbors.

The federal tobacco program, established in the 1930s, created the system sustaining small farmers for seven decades:

Production quotas limited supply to maintain prices. The federal government assigned each farm a quota specifying how many pounds it could sell. Quotas constrained production, preventing oversupply that would collapse prices.

Price supports guaranteed minimum prices, eliminating the worst downside risk. Farmers knew they could sell their quota at a set price regardless of market conditions.

Allotment inheritance passed quotas through generations like land itself. A family’s tobacco allotment was often the most valuable asset the family possessed, sometimes worth more than the land it covered. Allotments could be leased but not easily sold, keeping production on family farms.

This system sustained an entire social structure. Small farms remained viable because tobacco income per acre exceeded any alternative. Young people could stay on family land because a few acres of tobacco provided income unavailable from other crops. Communities maintained population because farming remained economically rational.

At its peak in the 1990s, nearly 60,000 Kentucky farms grew tobacco. The crop generated 25% of Kentucky’s agricultural cash receipts. North Carolina had over 12,000 flue-cured tobacco farms. Virginia Southside depended on tobacco as its primary agricultural product.

The Tobacco Buyout

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The Fair and Equitable Tobacco Reform Act of 2004 ended the quota system. The buyout responded to multiple pressures: the Master Settlement Agreement creating legal liability for tobacco companies, declining demand as smoking rates fell, and political pressure from agricultural economists who viewed the quota system as economically inefficient.

The buyout provided nearly $10 billion to purchase quotas and compensate growers. Payments were distributed over ten years, with amounts based on historical production.

The effects were predictable:

Farm consolidation accelerated dramatically. Without quotas constraining production, tobacco farming shifted to large-scale operations with mechanization and economies of scale. The 2022 Agricultural Census counted only 2,987 farms growing tobacco nationally, down 95% from 56,977 in 2002. Kentucky dropped from approximately 24,000 tobacco farms to 984.

Payment distribution was highly unequal. An estimated 20% of growers received more than 75% of total payments. Large operations with substantial historical production received substantial payments. The median payout was less than $15,000 annually for ten years, insufficient to sustain small farming operations through transition to alternatives.

Land use changes followed. Without tobacco income, small farms became uneconomic. Some converted to hay or cattle. Some were sold to larger operations. Some became exurban residential property. The agricultural landscape transformed.

The small farmers who needed transition assistance most received the least. They had the smallest quotas, the highest production costs per pound, and the fewest alternatives.

Twenty Years After

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Two decades after the buyout, the Upland South remains in economic transition without clear destination:

Manufacturing provided employment as tobacco declined but has itself declined. Textile mills that once supplemented farm income have closed. Furniture factories have moved offshore. The manufacturing employment that might have absorbed displaced tobacco farmers no longer exists in sufficient quantity.

Tourism and amenity economies have transformed some communities, particularly those near metropolitan areas or with natural attractions. The North Carolina Piedmont near Charlotte and the Research Triangle has attracted technology employment. Kentucky bluegrass country markets bourbon tourism. But most communities lack tourism assets or proximity to growing metropolitan areas.

Alternative agriculture succeeds in limited niches. Hay, cattle, and timber provide some income but require more acreage for equivalent returns. Specialty crops like produce, wine grapes, and hemp have attracted attention but cannot absorb all displaced farmers.

Commuting has become the dominant strategy. Residents increasingly drive 30-90 minutes to employment in metropolitan areas or regional centers while living in rural communities. This maintains residential population but transforms community character, with working-age adults absent during business hours.

The net effect is communities that remain rural in geography and culture but lack the economic base that sustained them for generations. Healthcare challenges emerge against this backdrop of extended economic uncertainty.

Current Conditions

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Health Outcomes

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The Upland South exhibits elevated chronic disease rates reflecting tobacco culture, limited healthcare access, and economic stress:

Tobacco use remains elevated in communities where growing tobacco was identity, not just livelihood. The same families who built their lives on tobacco continue using it at rates well above national averages. Anti-smoking campaigns designed elsewhere face cultural resistance when they appear to condemn communities’ heritage.

Chronic disease reflects smoking, diet, limited healthcare access, and economic stress. Diabetes prevalence exceeds national rural averages. Heart disease mortality is substantially elevated. The combination of cultural factors and access barriers produces outcomes that statistics capture but cultural context explains.

Opioid crisis affects the Upland South alongside adjacent Appalachian communities. Prescription opioid prescribing patterns established during the pain management era created addiction pathways. Economic distress contributes to substance use disorders.

The Trust Problem

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The fundamental healthcare challenge is trust, not infrastructure. Communities distrusting government distrust government healthcare programs:

Medicaid expansion resistance: Several Upland South states did not expand Medicaid under the ACA. North Carolina expanded only in late 2023 after a decade of resistance. Tennessee still has not expanded. Georgia expanded in 2024 but with work requirements that limit enrollment. Virginia expanded in 2019.

ACA marketplace skepticism: Even where marketplace coverage is available, enrollment rates lag. Subsidies are government assistance; government assistance carries stigma. Navigators report that eligible individuals decline enrollment rather than accept what they perceive as charity.

Program non-participation: Eligible individuals do not enroll in programs they qualify for. SNAP, CHIP, WIC, and other means-tested programs have lower participation rates in Upland South counties than in communities without similar cultural resistance. This is not primarily an awareness problem; it is a stigma problem.

Clinical recommendation resistance: Patients may resist provider recommendations perceived as outside imposition. Preventive care recommendations from physicians trained in academic medical centers may face skepticism when they conflict with family practices or community norms.

Core Tensions

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Regional Identity vs. External Characterization

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The internal identity view holds that Upland South communities should define themselves and their challenges. Residents are proud of their heritage, faith, and family bonds. They have managed their communities for generations. External characterization as poor, unhealthy, or in need of rescue imposes outside perspectives that do not match how communities see themselves. Transformation should engage how communities see themselves, not how outsiders see them.

The analytical necessity view acknowledges communities may not see structural causes of their challenges. High chronic disease rates and healthcare access barriers are real regardless of community self-characterization. Accurate assessment, even if uncomfortable, is necessary for effective intervention. Respecting community identity cannot mean pretending problems do not exist.

The evidence suggests both views must be held simultaneously. Communities have genuine strengths transformation should engage. Communities also face genuine challenges transformation should address. The goal is intervention respecting identity while improving outcomes, not choosing between respect and effectiveness.

Self-Determination vs. Effective Intervention

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The self-determination imperative insists communities should determine their own transformation. Outside-designed programs may not fit community values or earn trust. Imposed transformation will be resisted, undermined, and ultimately rejected. Self-determination is not merely an ethical preference but a practical necessity given cultural patterns.

The effective intervention reality recognizes self-determination requires capacity distressed communities may lack. Evidence-based interventions developed elsewhere may be more effective than locally designed alternatives. Communities lacking healthcare expertise may design programs that feel appropriate but produce inferior outcomes. Pure self-determination may mean no transformation at all.

The evidence suggests hybrid approaches work best: external resources supporting community-controlled implementation. Programs designed with genuine community input, implemented through trusted institutions, and accountable to community members succeed where imposed programs fail.

Engaging Trusted Institutions vs. Maintaining Boundaries

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Churches and faith communities are the most trusted institutions in the Upland South. Ministers have moral authority that public health officials lack. Effective transformation might engage churches as partners, extending healthcare through trusted community anchors.

Boundary concerns caution against programs blurring church-state lines or channeling government resources through institutions with particular theological commitments. Faith-based programming may not serve all community members equally. Religious criteria could affect care delivery in ways that create disparities.

The evidence suggests partnership with faith communities can improve outcomes when structured appropriately. Health ministries, church-based health fairs, and congregation-based programming reach populations that secular programs miss. But partnership requires attention to boundaries, inclusion, and ensuring that religious participation is not a condition of healthcare access.

Alternative Perspective: The Regional Romanticism Critique

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Some argue that celebrating Upland South community excuses system failures:

1. “Strong community” narratives justify abandonment. If communities support each other informally, formal services seem unnecessary. Celebrating mutual aid excuses inadequate public provision.
2. Cultural explanations for health outcomes blame victims rather than structural barriers. Attributing high smoking rates to tobacco culture obscures economic stress and addiction pathways.
3. Respecting community values that include resistance to healthcare enables poor outcomes. Values are not beyond critique. Cultural competency can become cultural surrender.
4. Self-determination rhetoric may reflect provider unwillingness to navigate difficult cultural terrain rather than genuine respect for community autonomy.

Assessment: This critique has merit but goes too far. Romanticizing community can excuse neglect. But dismissing community strengths ignores assets effective intervention should leverage. The goal is neither romance nor dismissal but honest engagement recognizing both strengths and challenges.

What Transformation Requires

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Community-Controlled Design and Implementation

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RHTP investment should flow through community institutions wherever possible:

Faith community partnership: Churches can host health programming, deploy health ministry teams, and connect community health workers to populations distrusting secular programs. Congregational health programs reach people who will not visit clinics.

Local health coalitions: Community coalitions including providers, civic organizations, churches, and residents can design interventions fitting community context. Local ownership increases acceptance.

Community health workers from communities: CHWs recruited from communities they serve bring trust outside providers cannot earn. A neighbor talking about diabetes management has credibility that a visiting specialist lacks.

Local decision-making authority: State RHTP plans should allow regional variation accommodating Upland South distinctiveness rather than imposing standardized approaches.

Building on Trusted Institutions

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Transformation should engage existing community anchors:

Agricultural extension services have longstanding community relationships built through decades of practical assistance. Health programming through extension infrastructure reaches populations who may not seek healthcare through clinical channels.

Volunteer fire and rescue services provide emergency response in communities too small for professional services. Training and equipping volunteer services extends healthcare capacity through community-controlled organizations.

Schools reach children and families who might not otherwise engage healthcare systems. School-based health services provide access points for communities with few providers.

Patience for Trust-Building

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Trust cannot be purchased or mandated. It must be earned through consistent presence and demonstrated respect:

Long-term commitment: Programs disappearing after grant cycles confirm suspicions that outside attention is temporary and self-interested. Sustained presence over years, not months, demonstrates commitment communities can trust.

Relationship investment: Providers and staff must invest in relationships transcending clinical encounters. Knowing families, attending community events, and being present between crises builds trust clinical visits cannot.

Cultural humility: Providers should approach communities as learners rather than experts with answers. Acknowledging that communities have knowledge and values deserving respect creates foundation for partnership.

Tolerance for slow progress: Transformation metrics expecting rapid improvement will show failure in the Upland South. Appropriate expectations recognize that changing community health patterns requires years, not program cycles.

What Transformation Cannot Achieve

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Trust deficits built over generations cannot be overcome in program cycles. Communities experiencing decades of outside characterization as backward or deficient will not suddenly embrace outside programs because funding appeared. RHTP runs through 2030. Four years is insufficient for trust transformation in communities with deep suspicion.

Programs communities do not want will not succeed regardless of evidence for effectiveness. Transformation approaches that communities reject will be undermined through non-participation and eventual abandonment.

RHTP cannot change cultural orientation toward government. Communities viewing government programs as threats will continue viewing them as threats. Transformation can work around this orientation but cannot eliminate it.

RHTP cannot restore the economic stability tobacco provided. The buyout ended an agricultural system sustaining communities for generations. Healthcare transformation cannot fill the void economic transition created.

State RHTP Engagement

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Virginia explicitly identifies Southside as a priority region in its RHTP application. The state’s 2019 Medicaid expansion improved coverage options. Virginia proposes workforce investment targeting the region. Specific engagement strategies for communities resistant to government programs remain underdeveloped but could build on existing extension service relationships.

North Carolina’s late 2023 Medicaid expansion improved coverage options for previously uninsured residents. The NC ROOTS regional hub model creates coordination infrastructure that could support community-engaged approaches. Explicit strategies for faith community partnership remain to be developed.

Tennessee’s continued non-expansion creates fundamental coverage gaps affecting Middle and East Tennessee tobacco country. Transformation capacity is limited when underlying coverage infrastructure is absent. Tennessee’s RHTP must work within these constraints.

Kentucky expanded Medicaid in 2014 under Governor Beshear, providing coverage foundation other Upland South states lack. The state’s tobacco transition has been particularly severe given Kentucky’s tobacco intensity. Eastern Kentucky Appalachian focus dominates state planning, with central Kentucky tobacco country receiving less explicit attention.

Recommendations

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For States: Identify and target tobacco-transition communities specifically; partner with faith communities through appropriate structures; deploy community health workers from local communities; allow regional flexibility; invest in trust-building with realistic expectations for timeline.

For CMS: Recognize tobacco-transition regions as distinct from other rural categories; permit faith community partnership structures; allow longer timelines for trust-building outcomes; require genuine community engagement; accept regional variation in what success looks like.

For Communities: Engage transformation on community terms; leverage faith community infrastructure; identify community health workers from trusted community members; define success measures reflecting community values; advocate for approaches respecting identity while addressing health needs.

Honest Assessment

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The Upland South presents transformation challenges that infrastructure and funding alone cannot solve. The region’s needs are real: elevated chronic disease, limited healthcare access, coverage gaps in non-expansion states. But cultural orientation means standard program approaches face resistance undermining effectiveness.

Transformation requires cultural engagement, not just resource deployment. Programs must earn trust. They must work through community institutions. They must respect values that external observers may question. They must proceed patiently when metrics demand rapid results.

The fifth-generation farmer with diabetes and no insurance represents the transformation challenge in human form. He needs healthcare. He is unlikely to accept healthcare offered as government assistance. Reaching him requires understanding his worldview, engaging his community, working through his church, and respecting his values even when those values complicate healthcare delivery.

Whether RHTP can accomplish this within program timelines and structures remains uncertain. Transformation is possible but requires approaches that standard program design does not typically provide. States and CMS recognizing this can design appropriate strategies. Those that do not will invest resources without achieving commensurate outcomes.