Poverty in rural areas

Rural societies are diverse, with a greater proportion of both people in higher socioeconomic groups and those with low pay than in urban populations.¹,² Scattered among the relatively wealthy landowners, commuters, and professionals are rural dwellers living on very low incomes.³,⁴ A recent BMJ editorial exhorted doctors to “combat the damage” of poverty.⁵ In doing so, doctors should look beyond the rural idyll and recognise that, as elsewhere in the world, poverty in Britain is not confined to cities.

Carr-Hill et al emphasised the importance of looking at very small units—individuals and their families—when considering health needs.⁶ This is particularly important in rural areas. In cities generalised observations about a street or electoral ward may be reasonably accurate, but in the country an affluent landowner and his socially isolated and underprivileged neighbour may be the only people for miles around.

Twenty per cent of the rural population of England and 25% of rural households live in “absolute poverty” (on an income of less than 140% of supplementary benefit entitlement).²,⁷ In rural Scotland in 1994, 49% of heads of households had annual incomes below £7800 (half the median Scottish wage). In remote areas such as the Outer Hebrides the situation was worse, with almost the whole population on “poverty” incomes.³ Elderly people are worst affected: 35% of poor rural households are elderly people living alone.

Employment trends help to explain such low incomes. The number of people employed in agriculture is decreasing. The trend is towards insecure, low paid, often part time work with limited potential for progression—for example, in tourism.⁸ Only 38% of women in rural development areas have paid employment, compared with a British average of 45.5%.¹ Rural dwellers are less likely to register as unemployed and more likely to migrate in search of work.²

Contrary to popular belief, rural homelessness is a substantial problem. In England alone, over 46 000 people, 11.6% of the country’s homeless, are in rural areas.⁹ The popularity of second homes and retirement homes has led to inflated property prices, unattainable by young people. Rented accommodation may be available only during winter, out of the tourist season. The sale of council houses has reduced the availability of low cost housing for rent.⁴

Townsend describes poverty as “financial inability to participate in the everyday styles of living of the majority.”¹⁰ The more recent, broader concept of “social exclusion,” developed within the European Union, may be more helpful. It shifts the focus from income and expenditure to multidimensional disadvantage, relating the individual to the society in which he or she lives.¹¹ Despite an increase in the size of many villages, services such as shops, schools, banks, police stations, and pubs have diminished.¹² People without their own transport and those with mobility problems have increasing difficulty in gaining access to services and are forced to use those local services that remain. They spend more per item at village stores than those who can drive to supermarkets. The rural rich can economise in ways that their poorer neighbours cannot. Similarly, independent transport is an expensive necessity in remote areas (77% of rural households have a car compared with an English average of 68%¹) and compounds the poverty of families on low incomes. The popular image of poor rural dwellers being uncomplaining seems to be true. Many compare their situation with the harsher conditions of the past rather than with the current lifestyles of the majority.³ Our knowledge of rural health need is limited,¹³ but it is both logical and justifiable to assume that poverty and poor health are associated in rural areas,¹⁴ just as they are in our towns and cities. We should not be blinded by the fact that rural poverty is hidden.