Esther Britt lay in an oversize casket the color of an overcast sky.
She wasn't always so heavy, but relatives say a string of illnesses and unhealthy choices pushed her weight past 350 pounds and led her here Wednesday afternoon -- lying at age 56 in Stevens Funeral Home as friends and family gathered in the red-upholstered pews. Four days earlier, her breathing had waned and her heart had failed.
"Her body was just tired, worn out," her sister Mary Britt, 54, said. "This is better for her. Hard for us, but better for her."
In this corner of southwest Virginia, cow-speckled fields and empty downtown streets tell of a slower, calmer life. It's a place where older men can be found around a table every morning drinking 25-cent coffee with the nearest Starbucks miles away. Residents will tell you little distinguishes the city of Radford and neighboring Pulaski County from elsewhere in rural America. That is what troubles health-care workers here most about a new study that found a sharp drop in life expectancy for women in the two communities.
According to the study, life expectancy for women dropped in nearly 1,000 counties but fell most in Radford and Pulaski. In 1983, life expectancy for women in the two jurisdictions was about 84 years. By 1999, it had dropped 5.8 years, to 78. No other jurisdiction in the nation had a decrease of more than 3.3 years.
Experts say they don't know why Radford and Pulaski stick out, but the study found life expectancy for women stagnant or falling in several other places in southern and southwestern Virginia.
For many who grew up and work here, the study validated what they already knew -- that women's health is faltering in part because of poor diets and smoking. Many men in the two communities face similar health troubles. Their life expectancy for the period studied fell about a year, to 72.
Local health experts said the study's findings for women are surprising.
"We do have some health challenges in southwest Virginia. But the extent that accounts for what is being reported today is a bit of a mystery to me," said Robert Parker, a spokesman for the Virginia Department of Health's southwest regional office. "It's like it pops up on your grandmother's front porch and you're not sure where it came from."
He said the department is "as interested in learning more about it as anybody."
This week, the department analyzed recent data and found that, in general, female death rates for Radford and Pulaski were consistent with rates for the region and the state.
Life expectancy, one of many ways of gauging the health of a population, is an estimate of how long the average person would live if the death rates at the time of his or her birth lasted a lifetime.
Jody Hershey, director of the New River Health District, said several factors that the study suggests for the drop in longevity come down to lifestyle choices. But in an area struggling economically, where the day's gas prices might determine whether it's worth a drive to the doctor's office, it's not always easy to push preventive measures, he said.
"If you are struggling to put food on the table, you don't have time to think about prevention," Hershey said, adding that lack of health insurance is significant problem in southwest Virginia.
On Main Street in the town of Pulaski, economic distress is clear. "For Sale" signs hang on several storefronts, and even at lunchtime, few people stroll the streets. It wasn't always like this, business owner David Allen said.
"This place was elbows to elbows walking down Main Street," he said. "This was where everybody came to shop."
That was before popular stores left and major manufacturers, such as Pulaski Furniture, where many residents worked, closed. Now everyone talks about expected layoffs at Volvo, a major employer.
"It's going downhill," John Stevens said. "We even lost a Wal-Mart here. Who loses a Wal-Mart?"
He and his brother Skip Stevens are the fourth generation to run the funeral home. They have seen a rise in requests for cremations, another sign of financial strain, they said. Cremation runs about $2,000, burial four times that.
The life expectancy study, published Tuesday in PLoS Medicine, an open-access journal of the Public Library of Science, found that the drop was not limited to any race or ethnicity but that it was more common in rural and low-income areas. Radford, population 16,000, is viewed as less of a blue-collar community than Pulaski County, population 35,000. But the two localities face many of the same health issues, officials said.
"Across the board, the lifestyles here are relatively unhealthy," said Stuart Goldstein, a local general surgeon. "People are born and raised on fast food." He said it's not unusual to see parents smoking in the car with their children and the windows rolled up.
Goldstein said that he sees many cases involving cancer of the throat, head and neck and that the number of gallbladder disease cases -- influenced by factors known as the "five F's": female, forty, fertile, fair and fat -- "is unreal."
Lynne Metzler, who oversees diabetes treatment for Carilion New River Valley Medical Center in Radford, said many patients expect to get diabetes because their mothers and grandmothers had it. She said that for many, the surprise comes not with the diagnosis but with the realization that they "don't have to lose a leg" or "go on dialysis."
Health-care providers said it is not unusual to find that women, who handle most of household health-care decisions, tend to put their health problems last.
Judy Opincar, 48, unemployed and on disability, said she knows she should have started taking care of herself sooner. She has high blood pressure, high cholesterol and diabetes, but it took her mother's death in December, at 69, to spur her to diet.
"That was the wake-up call," Opincar, who weighs 250 pounds and hopes to qualify for gastric bypass surgery, said. "I'm built exactly like her, and I don't want that to happen to me."
When her twin sons were little, she said, she cooked every night. But now, with only herself to care for, she said she either turns to the microwave or finds herself at one of many fast-food options on "Hamburger Row" near a bridge that divides Radford and Pulaski.
She met her friend Carol Agee at Wendy's on Wednesday for dinner. Both struggle with their weight and are helping each other make changes, if only incremental. Opincar passed on the fries with her spicy chicken sandwich, and Agee said she has limited her eating out to about five times a week.
"You're doing better," Opincar told her.
"That's pretty bad when that's better," Agee said.
Officials in both localities point to initiatives to improve heath. A state-of-the-art recreation center in Radford is free to residents, said Mayor Thomas L. Starnes, who frequents the city's five miles of trails. Pulaski County Administrator Peter M. Huber pointed to the area's two state parks, a speedway, a fairgrounds and many ballfields.
Esther Britt, described at her funeral as a "spitfire," worked as a nurse at one point. But it was clear that by the time she died, she had taken better care of others than herself. She smoked a pack and a half of cigarettes a day and ate as much as she wanted, Mary Britt said.
Her sister's illnesses and ailments were many: gallbladder disease, a degenerative disc in her back, bursitis in one shoulder, arthritis in the other, carpal tunnel syndrome, a hiatal hernia and diabetes. Recently, a tracheal tube was inserted to help her breathe. Her family traces the beginning of her decline to a car accident in her late 20s that shattered her ankle and eventually led to the amputation of her lower left leg.
"She's had every type of surgery you can think of," Britt said. "And each time she'd get a little down and then pick right back up again."
A day after the funeral, Britt stood at her sister's flower-laden grave and pointed to two untouched patches of green nearby. One is where she will be buried, next to her sister, and the other is where their mother will lie.